Separation Anxiety Disorder (SAD)


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In order to qualify for a DSM-IV-TR (2000) diagnosis of Separation Anxiety Disorder (SAD; 309.21), a client must present with the following essential features:

A)    Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attacked, as evidenced by three (or more) of the following:

  1. Recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated
  2. Persistent and excessive worry about losing, or about possible harm befalling, major attachment figures
  3. Persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped)
  4. Persistent reluctance or refusal to go to school or elsewhere because of fear of separation
  5. Persistently and excessively fearful or reluctant to be along or without major attachment figures at home or without significant adults in other settings
  6. Persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home
  7. Repeated nightmares involving themes of separation
  8. Repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated.

B)    The disturbance must last for a period of at least 4 weeks.

C)    The disturbance must begin before age 18.

D)    The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.

E)     The disturbance does not occur exclusively during the course of a Pervasive Development Disorder (PDD), Schizophrenia, or other Psychotic Disorder and, in adolescents and adults, is not better accounted for by Panic Disorder with Agoraphobia.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 125)

Separation Anxiety Disorder (SAD) is not uncommon; prevalence estimates average about 4% in children and young adolescents.  SAD decreases in prevalence as kids get older.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 123)  Some researchers argue that SAD is actually an early manifestation of panic disorder, rather than just a risk factor or precursor.  (Jurbergs & Ledley, 2005)

Treatment of SAD often involves a multimodal approach that may include psycho-education of the patient and family, school consultation and intervention, pediatrician consultation and pharmacotherapy, and cognitive-behavior therapy (CBT).  Research has repeatedly demonstrated the efficacy of CBT for children with SAD, supporting it as the best-proven treatment.  (Jurbergs & Ledley, 2005)  CBT has become a respected and empirically established model of psychotherapy in adults.  The fundamental principles of CBT can be applied to children with developmental modifications.  David Dia’s (2001) case study of a six year old boy named “Colt” serves as a great example.  Utilizing family education, progressively more difficult stress scenarios, and a token/exchange system; Colt’s belief was challenged and modified.  (Dia, 2001)

Although the cognitive technique of guided discovery and education proved fruitful in Colt’s case, I would underscore the importance of modifying CBT methods that were traditionally designed for adult patients.  Grover and associates (2006) provide the following examples of modification:

Relaxation and breathing techniques can be adapted for the younger child by using balloon (e.g., breath in and make your tummy fill up like a balloon) and robot/rag doll (e.g., tense your muscles like a robot, relax like a rag doll) metaphors. Depending on the cognitive level of the child, cognitive restructuring techniques may be simplified to teaching the child self-statements like, “Everything will be OK,” or, “I can handle my worries by myself.” One 9-year-old boy with SAD liked to use the coping statement, “Mom has always come back for me before.”  (Grover, Hughes, Bergman, & Kingery, 2006)

Pharmacotherapy should be used in conjunction with CBT only when the child’s symptoms have not responded to CBT interventions alone.  Selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and benzodiazepines have all been used to treat a number of anxiety disorders in children, including SAD, but no medications have specific indications for SAD.  (Jurbergs & Ledley, 2005)

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References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Dia, D. A. (2001, May). Cognitive-behavioral therapy with a six-year-old boy with separation anxiety disorder: A case study. Health & Social Work, 26(2), 125-129. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=73283346&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Grover, R. L., Hughes, A. A., Bergman, R. L., & Kingery, J. N. (2006, Fall). Treatment modifications based on childhood anxiety diagnosis: Demonstrating the flexibility in manualized treatment. Journal of Cognitive Psychotherapy, 20(3), 275-287. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1126879061&sid=6&Fmt=3&clientId=4683&RQT=309&VName=PQD

Jurbergs, N., & Ledley, D. R. (2005, Sep). Separation anxiety disorder. Psychiatric Annals, 35(9), 728-736. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=905192971&sid=6&Fmt=4&clientId=4683&RQT=309&VName=PQD

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