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

Anxiety Disorders: Separation Anxiety Disorder

Prof. Debbie van der WesthuizenHead: Child and Adolescent Units

Weskoppies Hospital

Page 2: 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

Page 3: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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)

Page 4: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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”

Page 5: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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

Page 6: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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

Page 7: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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

Page 8: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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

Page 9: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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

Page 10: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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

Page 11: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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

Page 12: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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)

Page 13: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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)

Page 14: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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

Page 15: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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

Page 16: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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

Page 17: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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)

Page 18: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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

Page 19: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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”

Page 20: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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

Page 21: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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)

Page 22: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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

Page 23: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

SAD co-morbidity

Page 24: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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)

Page 25: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

Prevention

• Target both parents and youth in prevention of SAD:

• parenting skills programs to improve

• parent-child relationships

• parenting style

• family functioning

• anxiety management

Page 26: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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

Page 27: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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

Page 28: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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

Page 29: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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

Page 30: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

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

Page 31: Anxiety Disorders: Separation Anxiety Disorder Prof. Debbie van der Westhuizen Head: Child and Adolescent Units Weskoppies Hospital

The End

• Questions?