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Child Planning: A Treatment Planning Overview for Children with Social Shyness

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A Treatment Overview for Children Experiencing Social Shyness

 

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 16 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:

 

Introduction

Causes and Symptoms

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:

 

Shyness is a common but little understood emotion. Everyone has felt ambivalent or self-conscious in new social situations. However, at times shyness may interfere with optimal social development and restrict children's learning. This digest (1) describes types and manifestations of shyness, (2) reviews research on genetic, temperamental, and environmental influences on shyness, (3) distinguishes between normal and problematic shyness, and (4) suggests ways to help the shy child.

 

The basic feeling of shyness is universal, and may have evolved as an adaptive mechanism used to help individuals cope with novel social stimuli. Shyness is felt as a mix of emotions, including fear and interest, tension and pleasantness. Increase in heart rate and blood pressure may occur. An observer recognizes shyness by an averted, downward gaze and physical and verbal reticence. The shy person's speech is often soft, tremulous, or hesitant. Younger children may suck their thumbs: some act coy, alternately smiling and pulling away (Izard and Hyson, 1986).

 

Shyness is distinguishable from two related behavior patterns; wariness and social disengagement. Infant wariness of strangers lacks the ambivalent approach/avoidance quality that characterizes shyness. Some older children may prefer solitary play and appear to have low needs for social interaction, but experience none of the tension of the genuinely shy child.

 

Children may be vulnerable to shyness at particular developmental points. Fearful shyness in response to new adults emerges in infancy. Cognitive advances in self-awareness bring greater social sensitivity in the second year. Self-conscious shyness-the possibility of embarrassment-appears at 4 or 5. Early adolescence ushers in a peak of self-consciousness (Buss, 1986).

 

Causes:

New social encounters are the most frequent causes of shyness, especially if the shy person feels herself to be the focus of attention. An "epidemic of shyness" (Zimbardo and Radl, 1981) has been attributed to the rapidly changing social environment and competitive pressures of school and work with which 1980s children and adults must cope. Adults who constantly call attention to what others think of the child, or who allow the child little autonomy, may encourage feelings of shyness.

 

Some children are dispositionally shy: they are more likely than other children to react to new social situations with shy behavior. Even these children, however, may show shyness only in certain kinds of social encounters. Researchers have implicated both nurture and nature in these individual differences.

 

Some aspects of shyness are learned. Children's cultural background and family environment offer models of social behavior. Chinese children in day care have been found to be more socially reticent than Caucasians, and Swedish children report more social discomfort than Americans. Some parents, by labeling their children as shy, appear to encourage a self- fulfilling prophecy, Adults may cajole coyly shy children into social interaction, thus reinforcing shy behavior (Zimbardo and Radl, 1981).

There is growing evidence of a hereditary or temperamental basis for some variations of dispositional shyness. In fact, heredity may play a larger part in shyness than in any other personality trait (Daniels and Plomin, 1985). Adoption studies can predict shyness in adopted children from the biological mother's sociability. Extremely inhibited children show physiological differences from uninhibited children, including higher and more stable heart rates. From ages 2 to 5, the most inhibited children continue to show reticent behavior with new peers and adults (Reznick and others, 1986). Patterns of social passivity or inhibition are remarkably consistent in longitudinal studies of personality development.

 

Despite this evidence, most researchers emphasize that genetic influences probably account for only a small proportion of self-labeled shyness. Even hereditary predispositions can be modified. Adopted children do acquire some of the adoptive parents' social styles (Daniels and Plomin, 1985), and extremely inhibited toddlers sometimes become more socially comfortable through their parents' efforts (Reznick and others, 1986).

 

Symptoms:

It is important to note that social shyness can sometimes be intermixed with anxiety disorder. Refer to anxiety disorder to compare behaviors. Shyness and social anxiety disorder are two different things. Shyness is a personality trait, and many people who are shy do not have the negative emotions and feelings that accompany social anxiety disorder.  They live a normal life, and do not view shyness as a negative trait. While many people with social anxiety disorder are shy, shyness is not a prerequisite for social anxiety disorder.

 

There are about 30 signs of social anxiety in children. Each sign individually is normal and most children will experience them at one time or another.  If this list better describes the child take a closer look at social anxiety:

 

1. Has a hard time talking to other kids and/or adults.

 

2. Excessively worries about their appearance.

 

3. Worries they might say something or do something embarrassing.

 

4. Struggles with ordering their own food at restaurants.

 

5. Is consumed with what other people think of them.

 

6. Has a hard time eating in front of other people when they are not at home.

 

7. Prefers to stay at home most of the time.

 

8. Feels overwhelmed in large social gatherings.

 

9. Worries parents are going to embarrass them in front of their friends.

 

10. Doesn’t like anyone to focus on them.

 

11. Is too anxious to raise their hand in class.

 

12. Overanalyzes social situations.

 

13. Often feels friends don’t really like them.

 

14. Has a hard time talking to people on the phone.

 

15. When they were very little they had a hard time separating.

 

16. When they were little they didn’t talk to anyone except family.

 

17. They have a hard time using the bathroom when they are not at home.

 

18. Refuses to poop anywhere, but home.

 

19. Feels like their friends don’t really care about them.

 

20. Is too anxious to do school presentations.

 

21. Is too anxious to read out loud in class.

 

22. Excessively worries that other people are judging them.

 

23. Is mortified if a teacher corrects them in front of other students.

 

24. Speaks softly to those they don’t know.

 

25. Fears new social situations.

 

26. Plays alone at school.

 

27. Has limited friends.

 

28. Teachers describe a completely different child than the one you see at home.

 

29. Gets self-conscious when their appearance changes (haircut, braces etc.).

 

30. Is overly afraid that kids will be mean to them.

 

Social Shyness Symptoms can be better described as:

 

  • Little or no eye contact

  • Refusal to respond verbally to social overtures

  • No contact with anyone outside the immediate family

  • Little contact with anyone outside the immediate family

  • Social isolation with no social activities

  • All or most activities are spend been alone

  • Hypersensitivity to disapproval or criticism

  • Excessive need for reassurance in order to get involved

  • Resistance to start new social activities

  • Does not take personal risks

  • Negative self image or self remarks

  • Lack of assertiveness

  • Lack of self confidence

  • Limited conversational skills,

  • Reluctance to interact with peers

  • Fear of rejection

  • Measure psychological distress in social settings

  • Manifested high anxiety symptoms

  • Compares unfavorably to others

  • Keeping others at a distance

 

When Is Shyness a Problem? Shyness can be a normal, adaptive response to potentially overwhelming social experience. By being somewhat shy, children can withdraw temporarily and gain a sense of control. Generally, as children gain experience with unfamiliar people, shyness wanes. In the absence of other difficulties, shy children have not been found to be significantly at-risk for psychiatric or behavior problems (Honig, 1987). In contrast, children who exhibit extreme shyness which is neither context-specific nor transient may be at some risk. Such children may lack social skills or have poor self-images (Sarafinio, 1986). Shy children have been found to be less competent at initiating play with peers. School-age children who rate themselves as shy tend to like themselves less and consider themselves less friendly and more passive than their non-shy peers (Zimbardo and Radl, 1981). Such factors negatively affect others' perceptions. Zimbardo reports that shy people are often judged by peers to be less friendly and likeable than non-shy people. For all these reasons, shy children may be neglected by peers, and have few chances to develop social skills. Children who continue to be excessively shy into adolescence and adulthood describe themselves as being more lonely, and having fewer close friends and relationships with members of the opposite sex, than their peers.

 

Treatment and Diagnosis:

 

Cognitive-Behavioral Therapy is highly effective in helping to reduce the symptoms social shyness. It focuses on improving thoughts, fears, and patterns of behavior. The goal is to first identify the thoughts that contribute to the social shyness. Then, objectively evaluate any beliefs about any situations that bring strong feelings of shyness. Finally, when minor is ready he or she is gradually, exposed to the feared situation, and replace thoughts and feelings with more positive responses to strengthen the changes in thoughts and beliefs.

 

Group therapy and social skills training classes can also be helpful components in any treatment plan. A full medical evaluation is recommended to rule out depression and evaluate medication needs. Some antidepressant and antianxiety medications such as the SSRI’s can be effective treatment for social anxiety. Research shows that a combination of psychiatric medication and cognitive behavioral therapy can have the most beneficial effect in decreasing social shyness symptoms.

As a therapist instruct parents to:

 

Know and Accept the Whole Child. Being sensitive to the child's interests and feelings will allow you to build a relationship with the child and show that you respect the child. This can make the child more confident and less inhibited.

 

Build Self-Esteem. Shy children may have negative self-images and feel that they will not be accepted. Reinforce shy children for demonstrating skills and encourage their autonomy. Praise them often. "Children who feel good about themselves are not likely to be shy" (Sarafino, 1986, p. 191).

 

Develop Social Skills. Reinforce shy children for social behavior, even if it is only parallel play. Honig (1987) recommends teaching children "social skill words" ("Can I play, too?") and role playing social entry techniques. Also, opportunities for play with young children in one-on-0one situations may allow shy children to become more assertive (Furman, Rahe, & Hartup, 1979). Play with new groups of peers permits shy children to make a fresh start and achieve a higher peer status.

 

Allow the Shy Child to Warm Up to New Situations. Pushing a child into a situation which he or she sees as threatening is not likely to help the child build social skill. Help the child feel secure and provide interesting materials to lure him or her into social interactions (Honig, 1987).

 

Remember That Shyness Is Not All Bad. Not every child needs to be the focus of attention. Some qualities of shyness, such as modesty and reserve, are viewed as positive (Jones, Cheek, and Briggs, 1986). As long as a child does not seem excessively uncomfortable or neglected around others, drastic interventions are not necessary.

 

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

 

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).

 

SOCIAL SHYNESS BEHAVIORAL DESCRIPTOR:

 

1. Little or no eye contact, and refusal to respond verbally to social overtures.

2. No or little contact with anyone outside the immediate family.

3. Social isolation with no social activities.

4. All or most activities are spend been alone.

5. Hypersensitivity to disapproval or criticism.

6. Excessive need for reassurance in order to get involved with others.

7. Resistance to start new social activities or take personal risks.

8. Negative self image or self remarks.

9. Lack of assertiveness due to fear of rejection.

10.Measure psychological distress in social settings, manifested by high anxiety symptoms.

 

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 SOCIAL SHYNESS:

 

1. End shyness and timid behavior in social settings.

2. Start a long term friendship with a peer outside the immediate family.

3. Learn to respond to social contacts in unfamiliar settings.

4. Learn how to act in new social settings.

5. Interact with others without high anxiety or fear levels.

6. Achieve a healthy balance between the time spent alone and in social activities.

7. Develop better social skills to increase social networking.

8. Increase self esteem.

9. Increase feelings of security.

10. Increase peer friendships at school.

 

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.

 

SHORT TERM GOALS FOR SOCIAL SHYNESS:

 

1. Complete necessary psychological testing.

2. Develop a trusting relationship with minor.

3. Develop behavioral strategies to increase social contacts.

4. Increase social contacts and conversation with others.

5. Agree to start a new social contact once a week or month.

 

 

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

 

INTERVENTIONS FOR SOCIAL SHYNESS:

 

1. Arrange for psychological testing to assess anxiety levels.

2. Refer for a medical or psychiatric evaluation and monitor medication compliance and side effects.

3. Build level of trust with minor using and encouraging constant eye contact to encourage expression of feelings.

4. Implement a systematic desensitization program to gradually increase the frequency and duration of social contacts.

5. Implement a reward system to reinforce engaging in social or recreational activities.

 

 

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 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 Social Shyness: (Parenthesis Represents ICD-10-CM Codes Effective 10-2014).

 

309.89 (F43.8) Other Specified Trauma- and Stressor-Related Disorder  

309.9 (F43.9) Unspecified Trauma- and Stressor-Related Disorder

309.21 (F93.0) Separation Anxiety Disorder

312.23 (F94.0) Selective Mutism

 

309.81 (F43.1 0) Posttraumatic Stress Disorder (includes Posttraumatic Stress

Disorder for Children 6 Years and Younger)

Specify whether: With dissociative symptoms

Specify if: With delayed expression

 

308.3 (F43.0) Acute Stress Disorder

 

Adjustment Disorders  Specify whether:

309.0 (F43.21) With depressed mood

309.24 (F43.22) With anxiety

309.28 (F43.23) With mixed anxiety and depressed mood

309.3 (F43.24) With disturbance of conduct

309.4 (F43.25) With mixed disturbance of emotions and conduct

309.9 (F43.20) Unspecified

 

300.23 (F40.1 0) Social Anxiety Disorder (Social Phobia)

Specify if: Performance only

300.01 (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,).

 

Panic Attack Specifier

300.22 (F40.00) Agoraphobia

300.02 (F41.1) Generalized Anxiety Disorder

300.09 (F41.8) Other Specified Anxiety Disorder

300.00 (F41.9) Unspecified Anxiety Disorder

 

Major Depressive Disorder

Single episode

296.21 (F32.0) Mild

296.22 (F32.1) Moderate

296.23 (F32.2) Severe

296.24 (F32.3) With psychotic features

296.25 (F32.4) In partial remission

296.26 (F32.5) In full remission

296.20 (F32.9) Unspecified

311 (F32.8) Other Specified Depressive Disorder

311 (F32.9) Unspecified Depressive Disorder

 

Problems Related to Family Upbringing

V611.20 (Z62.820) Parent-Child Relational Problem  

V61.8 (Z62.891) Sibling Relational Problem  

V61.8 (Z62.29) Upbringing Away From Parents

V611.29 (Z62.898) Child Affected by Parental Relationship Distress

Other Problems Related to Primary Support Group

V611.03 (Z63.5) Disruption of Family by Separation or Divorce

V61.8 (Z63.8) High Expressed Emotion Level Within Family

V62.82 (Z63.4) Uncomplicated Bereavement

 

Child Maltreatment and Neglect Problems  Child Physical Abuse

 

Child Physical Abuse, Confirmed

995.54 (T74.1 2XA) Initial encounter

995.54 (T74.1 2XD) Subsequent encounter

Child Physical Abuse, Suspected

995.54 (T76.12XA) Initial encounter

995.54 (T76.1 2XD) Subsequent encounter

 

Child Sexual Abuse

Child Sexual Abuse, Confirmed

995.53 (T74.22XA) Initial encounter

995.53 (T74.22XD) Subsequent encounter

Child Sexual Abuse, Suspected

995.53 (T76.22)(A) Initial encounter

995.53 (T76.22XD) Subsequent encounter

 

Child Neglect

Child Neglect, Confirmed

995.52 (T74.02XA) Initial encounter

995.52 (T74.02XD) Subsequent encounter

 

Child Psychological Abuse

Child Psychological Abuse, Confirmed

995.51 (T74.32XA)  Initial encounter

995.51 (T74.32XD) Subsequent encounter

Child Psychological Abuse, Suspected

995.51 (T76.32XA) Initial encounter

995.51 (T76.32XD) Subsequent encounter


 

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:

 

Present Behavioral Descriptors of Problem:

 

  1. Little or no eye contact, and refusal to respond verbally to social overtures.

  2. Social isolation with no social activities.

 

Long Term Goals:

 

  1. End shyness and timid behavior in social settings.

  2. Learn to respond to social contacts in unfamiliar settings.

 

Short Term Goals Objectives:

 

  1. Develop behavioral strategies to increase social contacts.

  2. Increase assertive behaviors to better deal with anxiety and stress.

 

Strategy  or Intervention for Goal 1:

 

  1. Encourage minor to attempt to initiate one social or conversation contact at least once a day.

  2. Help define extracurricular activities, and encourage minor to participate in at least one extracurricular activity in school.

  3. Help minor develop a list of strengths and interests, and encourage minor to use one of those strengths or weakness once a week to increase social contacts.

 

Strategy  or Intervention for Goal 2:

 

Build level of trust with minor using and encouraging constant eye contact to encourage expression of feelings.

Implement a systematic desensitization program to gradually increase the frequency and duration of social contacts.

Teach minor how to reduce anxiety using guided imagery and relaxation techniques.

 

DSM V Diagnosis:

 

300.02 (F41.1) Generalized Anxiety Disorder

 

308.3 (F43.0) Acute Stress Disorder


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