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Anxiety Disorders:
Separation Anxiety Disorder
Prof. Debbie van der Westhuizen
Head: Child and Adolescent Units
Weskoppies Hospital
Separation anxiety is very normal among preschoolers, especially those
who are going to school for the first time
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)
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”
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
Case: Living in her parent's shadow
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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
History of present complaint
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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
Past history
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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
Past history
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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
MSE
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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
MSE
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Susan's mood was described by her mother as anxious
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There was no evidence of psychosis
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Her thinking was logical and coherent
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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
Psychotherapeutic perspective
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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)
Diagnostic formulation
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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)
Psycho therapeutic perspective
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Susan's parents behave in a manner that allows her to avoid
S
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
Psycho therapeutic treatment
recommendations
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First choice treatment for Susan is CBT (cognitive-behavioral
therapy). Numerous independent studies have supported the shortterm 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
Psycho-therapeutic treatment goals
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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
Additional interventions
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If academic difficulties at initial; assessments, further neuropsychological 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)
Psycho-pharmacological perspective
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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
Diagnosis: separation anxiety disorder
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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”
Treatment: separation anxiety disorder
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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
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)
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
SAD co-morbidity
Other Anxiety
Disorders: GAD
(general anxiety
disorder- many
worries), Specific/Social phobia, OCD
(obsessive compulsive
disorder)
Enuresis,
Dysthymic
disorder, MDD
(major depressive
disorder)
ADHD (attention-deficithyperactivity disorder), ODD
(oppositional defiant disorder)
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 child’s 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 child’s self-help task)
Prevention
• Target both parents and youth in prevention of SAD:
• parenting skills programs to improve
• parent-child relationships
• parenting style
• family functioning
• anxiety management
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
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
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Family intervention crucial in school refusal
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
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, problemsolving exposure, relapse prevention
• Parent-child interaction therapy
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 ImpressionsImprovement 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
The End
• Questions?