Anxiety Disorders: Separation Anxiety Disorder

1. Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital Anxiety Disorders: Separation Anxiety Disorder

2. Separation anxiety is very normal among preschoolers, especially those who are going to school for the first time

3. 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)

4. 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”

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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)

13. 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)

14. 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 S

15. 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

16. 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

17. 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)

18. 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

19. 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”

20. 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

21. 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)

22. 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

23. SAD co-morbidity

24. 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)

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

26. 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

27. 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

28. 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

29. 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

30. 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

31. The End • Questions?