COURSES ARTICLE - THERAPYTOOLS.US. Child Planning: A Treatment Planning Overview for Children with Phobias

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1 COURSES ARTICLE - THERAPYTOOLS.US Child Planning: A Treatment Planning Overview for Children with Phobias A Treatment Overview for Children with Phobias 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 22 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 Symptoms Causes 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: Phobias create feelings of fear so intense that they disrupt the child s daily life and routine. They go far beyond the ordinary fears of childhood, and do not subside even with reassurance from parents or other caregivers. A phobia is an identifiable and persistent fear that is excessive or unreasonable and is triggered by the presence or anticipation of a specific object or situation. Children and adolescents with one or more phobias consistently experience anxiety when exposed to the specific object or situation. Common phobias include fear of animals, blood, heights, closed spaces, or flying. In children and adolescents, the identified fear must last at least six months to be considered a phobia rather than a transient fear. Anxiety disorders are common in all ages. The occurrence of specific phobias in children and adolescents is estimated to range from 1 percent to as high as 9.2 percent. While specific phobias often begin in childhood, they must be differentiated from normal developmental fears. Social anxiety disorder is estimated to occur in up to 1.4 percent of children and adolescents. Panic disorder can develop at any age, but most often begin in adolescence or young adulthood. What are symptoms seen in a child with a phobia? Symptoms: The following are the most common symptoms that may occur when a child or adolescent is exposed to, or anticipates exposure to, a specific object or situation that produces intense fear or anxiety. However, each child experiences symptoms differently. Symptoms may include:

3 increased heart rate sweating trembling or shaking shortness of breath feeling of choking chest pain or discomfort upset stomach feeling dizzy or faint fear of losing control or going crazy fear of dying numbness chills or hot flashes In panic attacks, at least four of the above listed symptoms must occur with or without a known and identifiable cause.

4 Please, note that symptoms of a phobia may resemble other medical conditions or psychiatric problems. Other Symptoms to Check for: Irrational fear of a specific object Fear poses little or no actual danger Irrational fear of a specific situation Phobic stimulus creates marked distress Anxiety affecting normal life routines Disturbed dreams of the feared stimulus or object Mentioning the phobic stimulus creates dramatic reaction Parents have contributed to the irrational fear or phobic stimulus Avoids phobic a stimulus at all costs Panic symptoms that occur when presented with a specific stimulus Unrelenting fear of object or situation

5 Awareness that the fear is irrational Incapacitating panic symptoms Concern about having additional attacks Unable to complete normal routines due to fear or anxiety problem Can t control feelings of fear Just thinking about the feared object creates anxiety When exposed the terror is automatic When exposed the fear is overwhelming Goes to great lengths to avoid object or situation Causes: Some common phobias in children include: animals blood

6 the dark enclosed spaces flying getting sick having a parent, sibling, or pet get sick or hurt heights insects and spiders needles ( getting shots at the doctor s office) thunder and lightning Many kids struggle with a specific fear of being physically separated from their parents or other family members. This is known as separation anxiety. Children with phobias might worry about the same subjects as children who don t have an anxiety disorder. The difference is that for a phobic child, there is no on-off switch for the fear: It s ever-present and so extreme that it interferes with her ability to relax, concentrate and enjoy activities. A phobia is a type of anxiety disorder, a condition that activates the fight or flight response and creates feelings of imminent danger that are out of proportion to the reality of the situation. Kids can develop anxiety disorders for many reasons, including:

7 biological factors: The brain has special chemicals, called neurotransmitters, that send messages back and forth to control the way a person feels. Serotonin and dopamine are two important neurotransmitters that, when out of whack, can cause feelings of anxiety. family factors: Anxiety and fear can be inherited. Just as a child can inherit a parent s brown hair, green eyes and nearsightedness, a child can also inherit that parent s tendency toward excessive anxiety. In addition, anxiety may be learned from family members and others who are noticeably stressed or anxious around a child. For example, a child whose parent shows immense fear of spiders may learn to fear spiders, too. environmental factors: A traumatic experience (such as a divorce, illness or death in the family) or even just a major life event like the start of a new school year may also trigger the onset of an anxiety disorder. Treatment and Diagnosis: It is important to note that nearly all infants and toddlers go through phases of one or more of the following at some point: demonstrating anxiety around strangers or in unfamiliar settings clinging to parents when introduced to new people becoming emotionally distressed when separated from a parent

8 Also, many kids struggle with a specific fear of being physically separated from their parents or other family members. This is known as separation anxiety. Similarly, most older children go through periods of fearing and worrying about: imaginary things, such as ghosts and monsters getting sick, hurt or dying having a parent, sibling, or pet get sick, get hurt or die thunderstorms, fires and other natural disasters However, if a child is suffering from a phobia, and not a transient fear, if she or he: experiences a particular fear for six months or longer feels such an extreme degree of fear and anxiety that daily activities, school life, family relationships and friendships are disrupted Social phobia vs Shyness: A shy child may feel uneasy when meeting new people or getting up in front of the class, but won t take extreme measures to avoid these situations and won t experience significant disruptions in their day-to-day lives. By contrast, a child with social phobia has a degree of fear and anxiety so severe that it: limits or otherwise interferes with daily activities

9 affects family relationships damages or impedes friendships impacts ability to function at school What are the symptoms of a specific phobia? Symptoms of specific phobia can include any or all of the following: avoiding the object of the phobia fearfully anticipating an encounter or experience with the phobic object enduring an encounter or experience with the phobic object while feeling such a high level of anxiety that the child s normal routines and activities are significantly disrupted What are the symptoms of panic disorder? The extreme fear and anxiety caused by panic disorder can manifest in such physical symptoms as: increased heart rate sweating trembling or shaking

10 shortness of breath a choking feeling chest pain or discomfort upset stomach feeling dizzy or faint a feeling of losing control or going crazy an I m going to die feeling numbness chills or hot flashes Experiencing four or more of these symptoms in a single episode is referred to as a panic attack. While panic attack symptoms can last for several hours at a time, they usually peak and then subside after 10 minutes. What are the symptoms of agoraphobia? Agoraphobia is an anxiety disorder characterized by symptoms of anxiety in situations where the person perceives the environment to be unsafe with no easy way to get away. These situations can include open spaces, public transit, shopping malls, or simply being outside the home. Children with agoraphobia will resist or outright refuse to leave home (or another place deemed safe ) for any reason. What are the symptoms of agoraphobia or social phobia?

11 Children with social phobia experience intense fear of one or more social or performance situations, including: being introduced to new people (whether peers or authority figures like teachers) interacting at parties or other gatherings giving a speech or presentation in front of the class asking questions in class being onstage for a school play or recital going out to eat at a restaurant using a public restroom when others are around talking on the phone While specific fears may vary, at the root of any case of social phobia is the child s overwhelming dread of being humiliated. Children with social phobia: feel extreme levels of anxiety while anticipating or experiencing a situation that may cause them embarrassment usually will seek to avoid potentially embarrassing situations at any cost

12 often resort to drastic measures to avoid or escape these situations (for example, refusing to go to school on the day of a book report or feigning illness when invited to a social gathering) 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,

13 psychological testing, contact with client s or patient s significant others at home, school, or work 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). PHOBIAS BEHAVIORAL DESCRIPTORS:

14 1. Irrational fear of a specific object or situation. 2. Phobic stimulus creates marked distress anxiety affecting normal life routines. 3. Disturbed dreams of the feared stimulus or object. 4. Mentioning the phobic stimulus creates dramatic reaction. 5. Parents have contributed to the irrational fear or phobic stimulus. 6. Avoids phobic a stimulus at all costs. 7. Panic symptoms that occur when presented with a specific stimulus. 8. Unrelenting fear despite awareness that the fear is irrational. 9. Incapacitating panic symptoms causing concern about having additional attacks. 10. Unable to complete normal routines due to fear or anxiety problem. 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 PHOBIAS: 1. Live phobia free and learning coping skills to respond to specific fears. 2. Decrease fear so that client can easily leave home and be comfortable in public environments. 3. Be able to travel away from home through enclosed transportation. 4. Decrease fear of the particular stimulus or situation (darkness, people, insects, etc.) that formerly caused immediate anxiety. 5. Reduce intrusion in normal routines and eliminate distress from feared object or situation. 6. Eliminate phobic symptoms and the fear that they will recur.

15 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 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 PHOBIAS: 1. Express and verbalize fear and focus on recounting the precise stimuli for it.

16 2. Help minor develop a hierarchy of different situations with different levels of phobic response. 3. Using art or play therapy have draw pictures of the feared stimulus objects or situations and process in therapy. 4. Help minor develop pleasant stories or story telling and encounter and overcoming the specific stimulus or object. 5. Help minor process dreams of the stimulus and give ending to disturbing dreams. 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 PHOBIAS: 1. Build a level of trust with minor to promote sharing of feelings. 2. Explore the minor's level and depth of fear, history and development of the phobia. 3. Help minor develop a clear hierarchy of different anxiety producing levels to help minor gain gradual control. 4. Use systematic desensitization (imaginary and real based) procedures to gradually expose minor to triggering stimuli. 5. Accompany minor to a vivo desensitization to gradually expose minor to triggering stimuli. Step 5, Diagnosis: 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

17 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: Possible Diagnostic Suggestions for Children with Specific Phobia: (Parenthesis Represents ICD-10-CM Codes Effective ) (F43.8) Other Specified Trauma- and Stressor-Related Disorder (F43.9) Unspecified Trauma- and Stressor-Related Disorder (F93.0) Separation Anxiety Disorder (F94.0) Selective Mutism (F43.10) Posttraumatic Stress Disorder (includes Posttraumatic Stress Disorder for Children 6 Years and Younger) Specify whether: With dissociative symptoms Specify if: With delayed expression (F43.0) Acute Stress Disorder (F40.1 0) Social Anxiety Disorder (Social Phobia) Specify if: Performance only (F41.0) Panic Attacks (Only if causes for Panic Attack can not be be better explained as a specifier within the context of that main disorder such as Anxiety Disorder, Post Traumatic Stress Disorder etc,).

18 Panic Attack Specifier (F40.00) Agoraphobia (F41.1) Generalized Anxiety Disorder (F41.8) Other Specified Anxiety Disorder (F41.9) Unspecified Anxiety Disorder 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. 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:

19 Present Behavioral Descriptors of Problem: 1. Irrational fear of a specific object or situation. 2. Phobic stimulus creates marked distress anxiety affecting normal life routines. 3. Panic symptoms that occur when presented with a specific stimulus. Long Term Goals: 1. Live phobia free and learning coping skills to respond to specific fears. 2. Decrease fear so that client can easily leave home and be comfortable in public environments. Short Term Goals Objectives: 1. Help minor develop a hierarchy of different situations with different levels of phobic response. 2. Help family members learn to demonstrate more support for minor. Strategy or Intervention for Goal 1: 1. Help minor develop a clear hierarchy of different anxiety producing levels to help minor gain gradual control. 2. Use systematic desensitization (imaginary and real based) procedures to gradually expose minor to triggering stimuli. Strategy or Intervention for Goal 2: 1. Help family become aware how they may reinforce the stimuli or phobia. 2. Confront any family modeling or patterns of phobic fears or responses.

20 DSM V Diagnosis: DSM V CODE Paired with ICD_9-CM COdes: Diagnostic Suggestions for Children with Specific Phobia: (Parenthesis Represents ICD-10-CM Codes Effective ) (F41.0) Panic Attacks (F40.00) Agoraphobia Copyright 2011 THERAPYTOOLS.US All rights reserved