Anxiety Disorders: Separation Anxiety Disorder

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Anxiety Disorders Separation Anxiety Disorder

• Prof. Debbie van der Westhuizen
• Head Child and Adolescent Units
• Weskoppies Hospital

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Separation anxiety is very normal among
preschoolers, especially those who are going to
school for the first time
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Separation anxiety (SA)

• SA is a developmentally appropriate response in
  young children on separation from primary
  caregivers (normal between 6 -30 months
  intensifies 13-18months declines between 3-5
  years due to cognitive maturation)

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Separation anxiety Disorder (SAD)

• SAD is a developmentally inappropriate
  excessive distress (worry/fear) associated with
  separation from primary caregiver 4 of
  school-aged children, common in 7- 8 year olds
• Only anxiety disorder in DSM-IV-TR included under
  disorders usually first diagnosed in infancy,
  childhood or adolescence

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SAD shadowing parents

• SAD is a developmentally inappropriate distress
  (excessive worry/fear) associated with separation
  from primary caregiver
• Anxiety may present prior to, during, and/or in
  anticipation of separation
• Fear that harm may come to themselves or parents-
  which will result in permanent separation
• Difficulty going to places without parents
• Specific themes nightmares of kidnap or being
  taken away
• To avoid separation complaints of
  stomach-aches/headaches

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Case Living in her parent's shadow

• Susan is a 7 year old referred due to concerns
  regarding anxiety and school refusal
• Chief complaint Susan is afraid I will forget
  her at school, her mother stated
• History of present illness For the past 3 months
  Susan had fears about separating from her parents
  to go to school, becoming progressively worse
• She has extreme distress on Sunday nights,
  trouble falling asleep with worries about bad
  things happening to her parents while at school
  a burglar will break into their house and kill
  her mother

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History of present complaint

• When in time for school, Susan actively resist by
  hiding under the bed or clinging to her mother
  while complaining about stomachache
• If she is at school, she intermittently appears
  sad and tearful, tells the teacher she needs to
  phone home to see if her mother is safe.
• She frequently asks to go to the nurses office as
  she has stomachache or feeling dizzy
• Her mom is considering quitting her job she is
  shadowing her parents at home and slipping into
  her parents' bed due to bad dreams of monsters
  capturing them

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Past history

• Psychiatric never participated in therapy or
  been given a prescription for psychotropic
  medication
• Medical history small for gestational age prone
  to illnesses as an infant
• Developmental history as infant and toddler slow
  to warm up to new people approached unfamiliar
  situations with avoidance separation reactions
  during preschool years
• Social history She lives with biological
  parents no history of abuse and neglect mother
  recently returned to work as a retail manager,
  limited contact with peers outside school

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Past history

• Family history Susan's mother has a history of a
  and panic disorder. Her father has recently been
  diagnosed with recurrent major depressive
  disorder and being treated with antidepressant
  medication. Susan's older brother has social
  phobia and dropped out of high school because of
  impairing fears and avoidance of social and
  performance situations
• Mental status evaluation Susan was nicely
  dressed and groomed appeared her stated age

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MSE

• She sat on her mother's lap during the
  evaluation engaged in minimal eye contact
• When asked direct questions- provided limited
  responses
• She refused to separate from her mother and would
  not allow her mother to leave the interview room
  without her
• Susan's mood was described as nervous and
  irritable at times of separation

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MSE

• Susan's mood was described by her mother as
  anxious
• There was no evidence of psychosis
• Her thinking was logical and coherent
• Susan stated that she would jump out of her
  mother's moving car if required to go to school
• While at home she constantly shadows her parents
  most evenings slips into parents bedroom afraid
  she will fall asleep and never wake up

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Psychotherapeutic perspective

• Susan presented with symptoms suggesting
  separation anxiety disorder (SAD) and problems
  with school refusal
• She experiences distress upon separation from her
  parents, worries that harm will befall them,
  afraid that she will be forgotten at school,
  refuses to go to school because of her separation
  concerns
• Distressed when at home without her parents
  will not sleep alone at night, has nightmares
  with separation theme reports stomachache and
  faintness
• Separation concerns present since preschool
• Susan's symptoms are reported to interfere
  meaningfully with her academic and social
  functioning ( unable to attend school or peers)

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Diagnostic formulation

• Multi-informant assessment would be helpful (data
  from Susan, parents, her school teacher)
• Self-report and teacher measures of anxiety an
  related emotional concerns
• Parent-and teacher's-report measures of Susan's
  behavior an index of academic achievement
  physical exam to rule out medical factors that
  may contribute to her symptoms. Paternal
  assessment for psychopathology given the mom's
  panic- and dad's depressive disorder
• Both biological and psychosocial factors likely
  play a role Susan may have been pre exposed
  (behavioral inhibition) as well as exposed to
  parents anxiety (modeling behavior)

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Psycho therapeutic perspective

• Susan's parents behave in a manner that allows
  her to avoid school and other anxious situations
• They pick her up from school when the nurse calls
  and let her sleep in their bed, allow her to go
  with dad to work instead of working on class work
• This pattern of parental accommodation to Susan's
  avoidance contributes to and maintains her
  anxious avoidance, which may prevent her from
  mastering age -appropriate developmental
  challenges

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Psycho therapeutic treatment recommendations

• First choice treatment for Susan is CBT
  (cognitive-behavioral therapy). Numerous
  independent studies have supported the short-term
  and long-term efficacy of CBT treatments
• CBT program would include having Susan to
  identify her somatic reactions to anxiety,
  identify and challenge her anxious thoughts,
  develop a plan to cope with anxiety-provoking
  situations, practice her coping plan, engage in
  exposure tasks, evaluate efforts at managing
  anxiety, therapist orchestrating role-play
  opportunities, teaching relaxation skills,
  modeling coping behavior, rewarding efforts
• Facilitate treatment gains by outside session
  activities (practicing skills learned in session)
• Parents to be orientated to treatment components
  and participate in exposure tasks

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Psycho-therapeutic treatment goals

• Improve Susan's coping skills by relaxation
  techniques to identify anxious thoughts, use
  appropriate coping thoughts and problem-solving
  strategies and to self-reward for effort
• As a result Susan will show a reduction in
  avoidance and anxious arousal
• She will start to return to school for partial
  then full day by reduction of phone calls made
  to her parents
• Be able to stay at home with babysitter and
  increase social activities (peers) Girl Scouts

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Additional interventions

• If academic difficulties at initial assessments,
  further neuro-psychological and
  psycho-educational testing may be needed
  (limitations in cognitive functioning could
  detract from treatment outcome)
• If parents experience distressing psychological
  symptoms, they should be referred appropriately
  for focused evaluation and treatment
• If treatment is unsuccessful (partially or
  completely) the number of CBT (cognitive
  behavior therapy) treatment sessions can be
  extended with augmenting CBT with Medication
  (SSRI)

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Psycho-pharmacological perspective

• Anxiety about attending school (main presenting
  problem) can be a manifestation of various
  concerns
• Evidenced by morbid feelings about parent's
  welfare, overwhelming wish to contact mother
  whenever school attendance has been forced,
  somatic symptoms at school with request to return
  home
• Parents are accommodating her avoidance behavior
  reflecting the parent's own anxiety
• Susan has difficulty sleeping in her own bed
  concerns about death and dying are not unusual in
  SAD
• Many children with SAD also have another anxiety
  disorder Susan is reported to also worry about
  school performance, family finances and peer
  acceptance a diagnosis of general anxiety
  disorder will only be considered if these worries
  reached clinical significance

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Diagnosis separation anxiety disorder

• The only diagnosis that is appropriate of Susan
  is that of separation anxiety disorder Susan's
  mom is reported to suffer from panic disorder and
  the dad from depression. Each disorder is
  associated significantly with SAD in off-spring
  and a history of both further increases the risk
• Fear something bad will happen to them or
  primary caretaker resulting in permanent
  separation

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Treatment separation anxiety disorder

• Treatment recommendations of childhood anxiety
  disorders is consistent with all other child
  psychopharmacology in that agents effectively in
  adults are used in children
• Well-documented efficacy of SSRIs (serotonin
  re-uptake inhibitors) in virtually all adult
  anxiety disorders have led to application in
  children anxiety disorders
• Fluoxetine is first choice, long-acting
  behavioral disinhibition (nastiness, rages,
  impulsiveness) is not rare in children treated
  with SSRIS (no standard dosages for children)
  start low go slow

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Diagnostic criteria for SAD

• A. Developmentally inappropriate-excessive
  anxiety concerning separation from home or those
  primarily attached
• 1.Recurrent distress when separation from
  home/attachments
• 2.Persistent worry about losing/harm befalling
  attachment
• 3.Persistent worry that event will lead to
  separation
• 4. Persistent reluctance/refusal to go to school
• 5.Peresistent fear/reluctance to be alone
• 6.Persistent reluctance/refusal to go to sleep
  alone
• 7.Repeated nightmares (theme of separation)
• 8.Repeated complaints of physical symptoms(
  headaches, stomach-aches)

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Diagnostic criteria for SAD

• B. Duration of disturbance at least 4 weeks
• C. Onset before age 18 years
• D. Disturbance causes clinical distress, or
  impairment in functioning (social, academic,
  occupational or other)
• E. Disturbance does not occur during PDD
  (pervasive developmental disorder)
  schizophrenia, or other psychotic disorders or
  better accounted for by agoraphobia
• Early onset before age 6 years

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SAD co-morbidity
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Aetiology, Mechanisms, Risk factors

• Attachment attachment theory suggests that
  predisposition to anxiety can be exacerbated or
  alleviated by type of mother-child attachment
• Temperament behavioural inhibition is a
  genetically based temperamental trait defined as
  childs reaction to unfamiliar situations
  increase the risk for SAD and other anxiety
  disorders at age 3
• Genetic and environmental factors a study
  supported both genetic and non-shared
  environmental contributions to SAD
• Parental anxiety Offspring of parents with
  anxiety disorders are at risk for developing
  them most common in children were SAD and GAD
• Parenting style parental rejection, parental
  control, and parental intrusiveness (unnecessary
  assistance with childs self-help task)

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Prevention

• Target both parents and youth in prevention of
  SAD
• parenting skills programs to improve
• parent-child relationships
• parenting style
• family functioning
• anxiety management

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Evaluation

• Formal evaluation to distinguish the specific
  anxiety disorder
• Assess severity of symptoms
• Determine functional impairment
• Assessing for diagnoses that may mimic anxiety
  disorders physical or other psychiatric
  conditions
• Interview parent(s) and child or together (not
  able)
• Contact teachers, or day-care on functioning in
  settings outside home

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Treatment

• Multimodal treatment plan where anxiety symptoms
  are moderate to severe with substantial
  impairment
• Psycho-education parents need assistance in
  understanding the nature of the anxiety (benefit
  when concerns are validated and self-blame
  minimized) School consultation
• CBT during initial sessions, parents child to
  be educated about behaviours that maintain SAD
  over time (avoidance of anxiety provoking
  situations) and treatment approaches to
  alleviate anxiety (thought identification,
  cognitive modification, behavioural exposures)
• Pharmacotherapy SSRIs first-choice medication
• Family intervention crucial in school refusal

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Treatment

• Behaviour modification gradual adjustment
  strategies to achieve a return to school and to
  separate from parents
• Biological off spring of parents with anxiety
  disorder and panic disorder with agoraphobia are
  prone to SAD
• SSRIs first-choice medication fluvoxamine
  (50-250mg/day) or fluoxetine (5-20mg/day) or
  Sertraline
• Benadryl (diphenhydramine) for control of sleep
  disturbances
• Alternative Tricyclic antidepressants (TCAs)
  more cardiovascular side-effects, dangerous in
  overdose
• Caution benzodiazepines only short-term,
  paradoxal disinhibition, addiction central
  nervous system depressant

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Psychotherapeutic treatments

• CBT (Cognitive-behavioural therapy for anxiety
  disorders) is best proven for youth with SAD
• Six essential CBT components include
  psycho-education, somatic management, cognitive
  restructuring, problem-solving exposure, relapse
  prevention
• Parent-child interaction therapy

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Psychotherapeutic treatments

• Child-Adolescent Anxiety Multi-modal study
  compared effectiveness of 12 weeks of sertraline
  vs CBT vs sertraline CBT, and placebo in
  moderate to severe SAD, GAD and/or SP
• Post-treatment (rated on Clinical Global
  Impressions-Improvement scale) very much
  improved 55 who received sertraline, 60- CBT,
  81 who received combination treatment and 24
  who received placebo
• Other individualized education plan effective
  strategies to help with coping in classroom

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The End

• Questions?