SEPARATION ANXIETY DISORDER

Presented by:

Shaista Butt

Definition

Separation anxiety disorder (SAD) accounts for approximately half of the referrals among all anxiety disorders usually diagnosed in infancy, childhood, or adolescence (Krain et al, 2007).

SAD is characterized by an abnormal reactivity to real or imagined separation from attachment figures that significantly interferes with daily activities and developmental tasks (Ono & Saito, 2012).

Age of Onset

Separation anxiety symptoms usually peak between 9 and 13 months of age, decrease usually after two years of age, with increasing levels of autonomy by the age of three.

Separation anxiety symptoms may increase again by age four to five, usually when the child starts school (Costello et al, 2005).

Signs and Symptoms The cardinal symptom is a significant distress, or

excessive and unrealistic fears, upon separation from parents or the home (APA, 2000). The child worries that something may happen to his parents (e.g., that they will disappear, get lost or forget about him) or the child will get lost, kidnapped or killed if he is not near his parents.

Behavioral:– Crying, – Clinging, – Complaining upon separation, – Searching or calling for the parent after their departure (Ono

& Saito, 2012).

Signs and Symptoms (Cont..)

Physical Signs:

– Headaches,– Abdominal pain,– Fainting spells, lightheadedness, dizziness,– Nightmares, sleep difficulties,– Nausea, vomiting,– Cramps, muscle aches,– Palpitations, chest pain (Ono & Saito, 2012).

Common situations:

Situations in which separation anxiety symptoms can appear are when the child (Ono & Saito, 2012) :

– Is left at daycare– Enters school– Gets on the school bus– Being bullied– Is left at home with baby

sitters– Begins summer camp

– Moves households– Stays overnight with

friends or relatives– Confronts parental

separation or divorce– Changes of school

DSM V Criteria Presence of at least 3 out of the 8 possible anxiety

symptoms that appear during separation situations (e.g., separation from home or from major attachment

figures; fear of losing or possible harm befalling to major attachment figures; reluctance or refusal to go to school, or be alone or without major attachment figures, etc.)

Symptoms must be present during at least four weeks, and must start before the age of 18.

Symptoms cause clinically significant level of distress or impairment in social, academic, occupational and other areas of functioning that is not explained by another disorder (Ono & Saito, 2012).

Co morbidity

Children with SAD more frequently present also with: – major depression (Angold et al, 1999), – bipolar disorder (Wagner, 2006), and – attention-deficit hyperactivity disorder.

Girls with the inattentive subtype of ADHD may have higher rates of comorbid SAD (Levy et al, 2005).

Prevalence and Epidemiology

SAD is probably the most common childhood anxiety disorder, with prevalence of 3%-5% in children and adolescents, and it decreases with increasing age (Costello & Angold, 1995).

Furthermore, almost all of the epidemiological studies that have been conducted so far have yielded that girls have high rate of SAD than boys (Veague, 2010).

Etiology and Pathogenesis The etiology of SAD is complex and partly unknown.

Studies demonstrate that both biological and environmental factors play a role, environmental factors might have a stronger influence in SAD than in other childhood anxiety disorders.

There is broad agreement that an interaction between different factors, biological and environmental, increases the risk for anxiety disorders. For example, the interaction of a mother with low anxiety

tolerance and a child with behavioral inhibition is likely to result in anxiety in the child.

(Ono & Saito, 2012).

Biological factorsGenetic Factors:

A large scale twin study suggested a significant genetic influence for SAD, accounting for a heritability of around 73% (Bolton et al, 2006).

Most studies suggest anxiety disorders run in families (Pine, 1999), and that a person can inherit vulnerability for any anxiety disorder.

Children with anxious parents are five times more likely to present an anxiety disorder.

Etiology (Cont..)Psychobiological:

Psychobiological processes such as fear conditioning are the underpinnings of anxiety disorders.

These are the product of genes and environment on the functioning of brain regions involved in fear and reward circuits (amygdala, orbitofrontal cortex, and anterior cingulate cortex) (Ono & Saito, 2012).

Dysfunction of some brain areas:

The amygdala is one of the main areas implicated in anxiety (Beesdo et al, 2009).

Environmental factors Related to the child’s family:

Factors related to child’s family that can cause anxiety include: – low parental warmth, – parenting behaviors that discourage child autonomy, – overprotective and over-involved parents, (Warren et al, 1997).

– Severe parental discord, – separation or divorce, – physical illness in a parent, – and mental disorder in a parent, such as panic disorder and

major depression (Pine & Klein, 2008).

Etiology (Cont..) Early experiences:

Stressful life events are broadly associated with pediatric psychopathology in general. o Being involved in a major disaster or crime, o exposure to family violence, o parent losing a job, o and birth of a sibling

(Ono & Saito, 2012). Related to the school:

Being bullied and failure to perform at the expected level in exams, sports or other academic activities can also play a role in developing separation anxiety.

Treatment There are multiple treatment options for children

suffering from SAD.

Most data about effectiveness of treatment refer to non-pharmacological treatments: – psycho-education, – behavioral intervention and – different forms of cognitive behavioral therapy.

(Ono & Saito, 2012).

Treatment (Cont..)Psycho-education:

Educating the family and the child increases insight and motivation. Understanding the nature of anxiety and how it is experienced by the child will help parents and teachers sympathize with a child’s struggles.

Psycho-education should always cover: – anxiety as a normal emotion, at all developmental stages; – factors that may trigger or maintain anxiety symptoms, – natural course of SAD, – treatment alternatives, including their advantages and

disadvantages and– prognosis (Ono & Saito, 2012).

Treatment (Cont..)

Behavioral interventions:

Numerous behavior therapy methods apply to children with SAD. – Systematic desensitization, – flooding implosive therapy, – contingency management and – modeling

• Systematic desensitization:

It involves teaching relaxation methods to cope with the anxiety sensations, and exposure to progressively more anxiety provoking situations. The list of intense situations is collaboratively produced by the therapist and the anxious child.

For example, a less intense but still anxiety-provoking situation that children with SAD might confront is being separated from their parent for 10 minutes while in their familiar house. A more intense situation might consist of being separated from their parent for a longer period while away from the home in an unfamiliar environment (such as a shopping center) (Ono & Saito, 2012).

• Flooding therapy:

It involves continuous actual exposure to the anxiety provoking situation. In this procedure, a therapist provides the anxious child with a sudden, intense exposure to a feared situation. Children are initially very anxious, but eventually habituate and calm down, having survived an experience of intense fear and living through it. The children learn that nothing bad has happened to them despite their fears.

For example, a child with SAD may be forced to go to school for a full day regardless of attempts to resist separation from caretakers (Ono & Saito, 2012).

• Contingency management:

Contingency management is a form of treatment found to be effective for younger children with SAD.

Contingency management revolves around a reward system with verbal or tangible, positive or negative reinforcement when the child displays separation anxiety. When children undergoing contingency management show signs of independence, they are praised or given a reward.

For example, rewards may be given each day the child attends school or goes to bed alone (Ono & Saito, 2012).

• Modeling:

Modeling can play an effective role in managing SAD.

Different modeling strategies used include live modeling, symbolic modeling, and participant modeling. – In live modeling, another child displays successful separation

from the parents. The child shows difficulty separating from parents initially followed by gradual mastery.

– In participant modeling the child with SAD repeats the modeled behavior after live modeling.

– In symbolic modeling, the therapist shows videotape of some other child successful separation from parents

(Ono & Saito, 2012).

Treatment (Cont..)Cognitive Behavioral Therapy:

CBT helps child in identifying anxiety cues and applying coping skills.

According to Kendall, there are four components that must be taught to a child undergoing CBT: 1) recognizing anxious feelings and behaviors,

2) discussing situations that provoke anxious behaviors,

3) developing a coping plan with appropriate reactions to situations, and

4) evaluating effectiveness of the coping plan.

(Seligman & Ollendick, 2011).

Treatment (Cont..) The child learns to identify cues that provoke anxiety by

self-monitoring e.g. separation from parents.

The child is then taught coping skills including positive self talk, PMR, distraction.

Lastly, the child applies these coping skills to those cues.

Cognitive behavioral therapies have the best evidence-based support for the treatment of the separation anxiety disorder in children and adolescents (Seligman & Ollendick, 2011).

.

CBT programs There are many CBT programs. Two of them are: The

Coping Cat and the Friends programs.

The Coping Cat program :

The Coping Cat (Kendall , 2000) is a manualized, proprietary intervention for youth with anxiety disorders, including SAD. The program incorporates cognitive restructuring and relaxation training followed by gradual exposure to anxiety-provoking situations applying learned coping skills. It has been shown to be effective in SAD (and also in generalized). Randomized clinical trials have achieved remission rates as high as 66% (Kendall et al, 1997).

The “Friends” program:

The Friends program is a 10-session CBT intervention delivered in a group format for children with anxiety disorders. FRIENDS is the acronym for: – F- Feeling worried?;– R- Relax and feel good; – I- Inner thoughts; – E- Explore plans, – N- Nice work so reward yourself; – D- Don’t forget to practice; and – S- Stay calm, you know how to cope now.

The program encourages families to develop supportive social networks, and children to develop friendships among group members and learning from peer’s experiences (Shortt et al., 2001).

Parent-Child Interaction Therapy (PCIT):

PCIT has been adapted for children aged four to eight with SAD (Brinkmeyer & Eyberg, 2003). It has three stages:

– Child-directed interaction: teaches parents to be warm and praiseful, to promote the child’s feeling of security in order to facilitate separation from the parent,

– Bravery-directed interaction: the therapist works with both the parents and the child to develop a list of situations the child is fearful of or currently avoiding, in order of severity. The family creates a reward list to reinforce the child’s efforts.

– Parent-directed interaction: parents learn how to manage the child’s misbehavior based on operant principles of behavior change Also, parents learn not to reinforce the child’s anxious behaviors, for example not giving the child more attention when he skips class (Eisen et al, 1998).

Pharmacological treatment:

Medication should always be used in addition to behavioral or psychotherapeutic intervention. Medication is not generally recommended as a first line treatment for SAD. However, various medications have been investigated for childhood anxiety disorders, such as – selective serotonin reuptake inhibitors (SSRIs), – tryciclic antidepressants (TCAs), – benzodiazepines, – buspirone, – antipsychotics, antihistamines and melatonin.

(Reinblatt & Riddle, 2007).

• Group play therapy has shown to have a significant effect on reducing separation anxiety disorder in children (Nauta, 2012).

• Art therapy has reduced the symptoms of SAD in elementary school boys while providing them with a creative outlet for their anxieties and emotions (Khadar, 2013).

Conclusion

The most recent evidence for empirically supported treatments shows that the CBT and selective serotonin-reuptake inhibitors (SSRI) are the most efficacious for the improvement of the children health with the separation anxiety disorder (Fisher et al., 2006).

ReferencesAmerican Psychiatric Association (2000). Diagnostic and

Statistical Manual of Mental Disorders (4th ed, text revision). Washington, DC: American Psychiatric Association.

Angold, A., Costello, E., & Erkanli, A. (1999). Comorbidity. Journal of Child Psychology and Psychiatry, 40, 57-87.

Brinkmeyer, M., & Eyberg, S. (2003). Parent-child interaction therapy for oppositional children. New York: Guilford.

Grohol, J. (2013). DSM-5 Changes: Anxiety Disorders & Phobias.  Retrieved from http://pro.psychcentral.com/dsm-5-changes-anxiety-disorders-phobias/004266.html