Historical background Definition Age of onset Signs and Symptoms DSM V Criteria Comorbidity Prevelance and Epidemiology Etiology and Pathogenesis Treatment Conclusion

1. SEPARATION ANXIETY
DISORDER
Presented by:
Shaista Butt

2. 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).

3. 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).

4. 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).

5. 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).

6. 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

7. 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).

8. 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).

9. 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).

10. 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).

11. Biological factors
 Genetic 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.

12. 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).

13. 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).

14. 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.

15. 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).

16. 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).

17. Treatment (Cont..)
Behavioral interventions:
Numerous behavior therapy methods apply to children
with SAD.
– Systematic desensitization,
– flooding implosive therapy,
– contingency management and
– modeling

18. • 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).

19. • 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).

20. • 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).

21. • 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).

22. 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).

23. 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).
.

24. 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).

25. 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).

26. 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).

27. 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).

28. • 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).

29. 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).

30. References
American 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