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Treatment For Separation Anxiety Disorder, Early Onset And 302.6 Gender Identity Disorder Nos?
Question: XXXXXXX is brought to you by his parents when he is seven years old and just starting second grade. He is small for his age and moves in a fashion that could be mistaken for a girl. His mother, XXXXXXX, is 34. She worked as an aide in a pre-school program that XXXXXXX attended until he entered kindergarten, “because XXXXXXX liked her to be there.” She now works with and for her 39 year-old husband, XXXXXXX XXXXXXX father. XXXXXXX owns and manages three convenience stores.
XXXXXXX has a 15 year old brother, XXXXXXX who is a very good athlete and already the highest scoring player on a competitive high school soccer team. This Muslim family emigrated from Pakistan ten years ago. They have since helped XXXXXXX parents move to the U.S. Assimilation into American culture is somewhat of a struggle from religious and cultural perspectives, particularly as the parents want to hold on to much of their culture of origin. Their English language skills are very good.
When they enter your office, XXXXXXX sits very close to his mother on one end of the sofa. His father sits in a separate chair. They speak with a strong Pakistani accent. They are concerned because XXXXXXX has been having stomachaches since the new school year started. They think he wants to stay home with XXXXXXX, because he behaved the same way in kindergarten and first grade for the first month or so of school. His complaints about stomachaches, though, are worse this year. He has always wanted someone to stay with him at night until he falls asleep but XXXXXXX put a stop to that at the start of kindergarten, “even though XXXXXXX cried like a baby.” XXXXXXX is a solid “A-B” student.
Since kindergarten, XXXXXXX has awakened frequently at night. He has been found sleeping outside his parents’ bedroom door on a number of nights because he has nightmares about his mother being kidnapped. They are concerned, too, because it was always a battle to get XXXXXXX to stay with a babysitter when he was a toddler. Eventually, they could only leave him with XXXXXXX parents for an evening because he wouldn’t stop crying if left with anyone else. Throughout the interview, XXXXXXX holds tightly to his mother’s sweater or hand, despite her obvious attempts to get him to sit up straight and to move away from her.
You ask XXXXXXX if he feels frightened, to which he nods, and says in a soft and somewhat breathy voice, “I worry all the time that something will happen to my mom.” He and his brother speak without accent. You ask if you can talk to him by himself. He responds by clinging to his mother, shaking his head, and saying, “I don’t want to. Don’t make me, please, mommy.” To which his father says, “Good lord,” rolls his eyes, and turns further away from XXXXXXX .
XXXXXXX personal history, and his family’s history on both sides, is unremarkable for mental or medical concerns or for physical or substance use or abuse disorders. There is no history of physical abuse, neglect, or domestic violence. All of XXXXXXX developmental signs fall within the norm. Other than his concerns of being away from his parents, he has no other behaviors of concern, except, his father says, with another eye roll, “He likes to play with girls and dolls and can’t stand getting dirty. He’ll never be the soccer player his brother is.”
1. What are your diagnostic hypotheses for XXXXXXX in this scenario?
Here is my diagnosis…
AXIS 1: 309.21 Separation Anxiety Disorder, Early Onset
302. 6 Gender Identity Disorder NOS
AXIS II: None
AXIS III: None
AXIS IV: School, Family, Social
AXIS V: 61
2. Describe what further diagnostic information you need (what further diagnostic evaluation is warranted).
3. From a diathesis-stress perspective, what impact do the cultural, ethnic and psychosexual issues have on XXXXXXX and his family in this scenario, and what other issues may play a role?
4. What would be the suggested course of treatment?
XXXXXXX has a 15 year old brother, XXXXXXX who is a very good athlete and already the highest scoring player on a competitive high school soccer team. This Muslim family emigrated from Pakistan ten years ago. They have since helped XXXXXXX parents move to the U.S. Assimilation into American culture is somewhat of a struggle from religious and cultural perspectives, particularly as the parents want to hold on to much of their culture of origin. Their English language skills are very good.
When they enter your office, XXXXXXX sits very close to his mother on one end of the sofa. His father sits in a separate chair. They speak with a strong Pakistani accent. They are concerned because XXXXXXX has been having stomachaches since the new school year started. They think he wants to stay home with XXXXXXX, because he behaved the same way in kindergarten and first grade for the first month or so of school. His complaints about stomachaches, though, are worse this year. He has always wanted someone to stay with him at night until he falls asleep but XXXXXXX put a stop to that at the start of kindergarten, “even though XXXXXXX cried like a baby.” XXXXXXX is a solid “A-B” student.
Since kindergarten, XXXXXXX has awakened frequently at night. He has been found sleeping outside his parents’ bedroom door on a number of nights because he has nightmares about his mother being kidnapped. They are concerned, too, because it was always a battle to get XXXXXXX to stay with a babysitter when he was a toddler. Eventually, they could only leave him with XXXXXXX parents for an evening because he wouldn’t stop crying if left with anyone else. Throughout the interview, XXXXXXX holds tightly to his mother’s sweater or hand, despite her obvious attempts to get him to sit up straight and to move away from her.
You ask XXXXXXX if he feels frightened, to which he nods, and says in a soft and somewhat breathy voice, “I worry all the time that something will happen to my mom.” He and his brother speak without accent. You ask if you can talk to him by himself. He responds by clinging to his mother, shaking his head, and saying, “I don’t want to. Don’t make me, please, mommy.” To which his father says, “Good lord,” rolls his eyes, and turns further away from XXXXXXX .
XXXXXXX personal history, and his family’s history on both sides, is unremarkable for mental or medical concerns or for physical or substance use or abuse disorders. There is no history of physical abuse, neglect, or domestic violence. All of XXXXXXX developmental signs fall within the norm. Other than his concerns of being away from his parents, he has no other behaviors of concern, except, his father says, with another eye roll, “He likes to play with girls and dolls and can’t stand getting dirty. He’ll never be the soccer player his brother is.”
1. What are your diagnostic hypotheses for XXXXXXX in this scenario?
Here is my diagnosis…
AXIS 1: 309.21 Separation Anxiety Disorder, Early Onset
302. 6 Gender Identity Disorder NOS
AXIS II: None
AXIS III: None
AXIS IV: School, Family, Social
AXIS V: 61
2. Describe what further diagnostic information you need (what further diagnostic evaluation is warranted).
3. From a diathesis-stress perspective, what impact do the cultural, ethnic and psychosexual issues have on XXXXXXX and his family in this scenario, and what other issues may play a role?
4. What would be the suggested course of treatment?
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Hi XXXXXXX
Your diagnosis of a Separation Anxiety Disorder is bang on target. The history fulfills all diagnostic criteria for this diagnosis:
(1) recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated
(2) persistent and excessive worry about losing, or about possible harm befalling, major attachment figures
(3) persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped)
(4) persistent reluctance or refusal to go to school or elsewhere because of fear of separation
(5) persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings
(6) persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home
(7) repeated nightmares involving the theme of separation
(8) repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated.
Regarding the diagnosis of Gender Identity Disorder, I would agree that there are hints for this in the history. But, with the information available, I think it is insufficient to make a definitive diagnosis. There are two reasons for this:
1) For a diagnosis of gender identity disorder, the symptoms should be "pervasive and persistent"
2)There should be significant "distress" to the person about the assigned sex.
Non-conformity to stereotypic gender roles is frequent in childhood. Such transient and mild behaviour does not quantify for a diagnosis of a Gender Identity Disorder. The ICD-10 diagnostic criteria specifically mention that there should be "profound disturbance" of the normal sense of maleness or femalenes; and mere 'tomboyishness in girls or 'girlish behaviour' in boys is not sufficient.
So, you are no doubt in the right track regarding your diagnostic approach, but it's just that we need more concrete evidence.
Further diagnostic information would be to check if XXXXXXX fulfills criteria for a Gender Identity Disorder.
- Wishes to be the opposite sex
- Belief that they will grow up to become the opposite sex
- Feelings of disgust by their own genitals
- Rejection by their peers, feeling alone
- Cross-dressing
Also, further psychodynamic exploration about the family dynamics and into the cultural acclamatization would be helpful in knowing if any of these factors could be contributory to the development of these problems.
From the perspective of a diathesis-stress model, in XXXXXXX case,
cultural and ethnic differences, leading on to problems in cultural acclamatization could constitute a "stress". It is well known that separation anxiety disorder runs in families, thus implying a partly genetic basis to the causation i.e. "diathesis". So, the environmental stress when superimposed on a genetically predisposed or vulnerable individual results in the pathogenisis of the disorder.
If we were to consider a possible diagnosis of a Gender Identity Disorder, then here too, the diathesis-stress model is quite applicanle. Parental attitudes towards the gender of the children, cultural norms and practices, etc. could all be contributing to the "stress" factor. For example, it has been found that G.I.D is more common in parents who have had high expectations for a child of a particular gender. When this expectation turns out to be unfulfilled and the child happens to be born of the opposite sex, some parents may project their unfulfilled desires and expectations on the child, for example, by dressing-up or bringing-up the child as one of the opposite sex. This can sometimes play a role in the development of G.I.D in such children.
Suggested course of Treatment:
First line treatment and usually very effective, especially for younger children is behaviour therapy. Systematic desensitization, exposure-based therapies and contingency management are some of the behavioural techniques used. Contingency management revolves around a reward system with verbal or tangible reinforcement.
Usually the child is forced to go to school and with time the symptoms of SAD keep decreasing and subside. The concept is that the more the child is out of school, the more reinforced and dysfunctional does this beahviour become.
Cognitive Behaviour Therapy can also be tried according to the intellectual capacity of the child. Goals in CBT are:
- Recognizing anxious feelings and somatic reactions to anxiety.
- Clarifying cognition in anxiety-provoking situations.
- Developing a plan to cope with the situation.
- Evaluating the success of the coping strategies and utilizing self-reinforcement.
In extreme cases of SAD, anti-anxiety medication can also be tried if behavioural and other psychological methods fail.
- Dr. Jonas Sundarakumar
Consultant Psychiatrist
(P.S: In addition to your rating for the answers, I would appreciate if you could also leave a review, when the query is closed.)
Your diagnosis of a Separation Anxiety Disorder is bang on target. The history fulfills all diagnostic criteria for this diagnosis:
(1) recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated
(2) persistent and excessive worry about losing, or about possible harm befalling, major attachment figures
(3) persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped)
(4) persistent reluctance or refusal to go to school or elsewhere because of fear of separation
(5) persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings
(6) persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home
(7) repeated nightmares involving the theme of separation
(8) repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated.
Regarding the diagnosis of Gender Identity Disorder, I would agree that there are hints for this in the history. But, with the information available, I think it is insufficient to make a definitive diagnosis. There are two reasons for this:
1) For a diagnosis of gender identity disorder, the symptoms should be "pervasive and persistent"
2)There should be significant "distress" to the person about the assigned sex.
Non-conformity to stereotypic gender roles is frequent in childhood. Such transient and mild behaviour does not quantify for a diagnosis of a Gender Identity Disorder. The ICD-10 diagnostic criteria specifically mention that there should be "profound disturbance" of the normal sense of maleness or femalenes; and mere 'tomboyishness in girls or 'girlish behaviour' in boys is not sufficient.
So, you are no doubt in the right track regarding your diagnostic approach, but it's just that we need more concrete evidence.
Further diagnostic information would be to check if XXXXXXX fulfills criteria for a Gender Identity Disorder.
- Wishes to be the opposite sex
- Belief that they will grow up to become the opposite sex
- Feelings of disgust by their own genitals
- Rejection by their peers, feeling alone
- Cross-dressing
Also, further psychodynamic exploration about the family dynamics and into the cultural acclamatization would be helpful in knowing if any of these factors could be contributory to the development of these problems.
From the perspective of a diathesis-stress model, in XXXXXXX case,
cultural and ethnic differences, leading on to problems in cultural acclamatization could constitute a "stress". It is well known that separation anxiety disorder runs in families, thus implying a partly genetic basis to the causation i.e. "diathesis". So, the environmental stress when superimposed on a genetically predisposed or vulnerable individual results in the pathogenisis of the disorder.
If we were to consider a possible diagnosis of a Gender Identity Disorder, then here too, the diathesis-stress model is quite applicanle. Parental attitudes towards the gender of the children, cultural norms and practices, etc. could all be contributing to the "stress" factor. For example, it has been found that G.I.D is more common in parents who have had high expectations for a child of a particular gender. When this expectation turns out to be unfulfilled and the child happens to be born of the opposite sex, some parents may project their unfulfilled desires and expectations on the child, for example, by dressing-up or bringing-up the child as one of the opposite sex. This can sometimes play a role in the development of G.I.D in such children.
Suggested course of Treatment:
First line treatment and usually very effective, especially for younger children is behaviour therapy. Systematic desensitization, exposure-based therapies and contingency management are some of the behavioural techniques used. Contingency management revolves around a reward system with verbal or tangible reinforcement.
Usually the child is forced to go to school and with time the symptoms of SAD keep decreasing and subside. The concept is that the more the child is out of school, the more reinforced and dysfunctional does this beahviour become.
Cognitive Behaviour Therapy can also be tried according to the intellectual capacity of the child. Goals in CBT are:
- Recognizing anxious feelings and somatic reactions to anxiety.
- Clarifying cognition in anxiety-provoking situations.
- Developing a plan to cope with the situation.
- Evaluating the success of the coping strategies and utilizing self-reinforcement.
In extreme cases of SAD, anti-anxiety medication can also be tried if behavioural and other psychological methods fail.
- Dr. Jonas Sundarakumar
Consultant Psychiatrist
(P.S: In addition to your rating for the answers, I would appreciate if you could also leave a review, when the query is closed.)
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
I have two more like this Im working on which are additions to this one. Instead of sending them as a follow-up question, I will send them like this one. I just want to make sure I'm paying you for your time and help which is greatly appreciated...Thank you
I will leave a review...
I will leave a review...
Thank you. I appreciate you kind gesture.
- Dr. Jonas Sundarakumar
Consultant Psychiatrist
- Dr. Jonas Sundarakumar
Consultant Psychiatrist
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Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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