Treating Separation Anxiety Using Cognitive Behavioral Therapy Shawn Powell & Brett Nelson

Transcription

1 Treating Separation Anxiety Using Cognitive Behavioral Therapy Treating Separation Anxiety Using Cognitive Behavioral Therapy Shawn Powell & Brett Nelson Separation anxiety presents significant challenges for children and their families (Kendall et al., 1997). Separation anxiety has a high rate of co-morbidity with other childhood disorders (Brückl, Wittchen, Höfler, et al., 2007; Hanna, Fischer, Fluent, et al., 2006) and has been linked to parental intrusiveness (Wood, 2006). If left untreated, anxiety from one environment can extend to other settings, objects, or events (Friman, Hayes, & Wilson, 1998). Additionally, separation anxiety is linked to emotional turmoil in adulthood (Vanderwerker, Jacobs, Parkes, & Prigerson, 2006). Cognitive-behavioral therapy (CBT) for childhood anxiety has been advocated for some time (Ronen, 1996). Parental involvement in CBT has also been advocated (Howard & Kendall, 1996). Several studies have reported positive outcomes by including parents and family members in the treatment of children with separation anxiety (Eisen, Raleigh, & Neuhoff, 2008; Pincus, Santucci, Ehrenreich, & Eyberg, 2008; Siqueland & Diamond, 1998). To illustrate the application of CBT in combination with parental involvement in the treatment of childhood separation anxiety, we present the case of Paul, a 10-year-old fourth grade boy. This case study suggests that the intervention used to reduce Paul s separation anxiety was effective. The inability to modify specific treatment conditions once they have been established due to clinical and ethical considerations is also highlighted. Intended Population Childhood separation anxiety occurs when children are required to be separated from their parents and caregivers. In this case, Paul displayed anxiety by crying and voicing concern for his mother s safety when he was left at school. The techniques described here could be applied to children displaying separation anxiety in a variety of settings including schools, preschools, daycare centers, and after-school programs. Client Description Paul s teacher referred him to the school psychologist because he cried and voiced concerns about missing his mother after she dropped him off at school. He had attended the same school for four years, and had not previously shown emotional distress or behavioral difficulties. He was not prescribed any medications during treatment, nor did he have a previous history of psychological treatment. The following is an excerpt from an interview with Paul s teacher: School Psychologist: What do you think is happening to make Paul cry? He s attached to his mother and doesn t like leaving home. School Psychologist: What happens when Paul is left at school? He cries and is having problems with some of his friends. He has a lot of friends in class, but he

2 154 Treating Separation Anxiety Using Cognitive Behavioral Therapy isn t playing with them. He is very sensitive and easy to knock off balance. He has difficulty with changes in his routine. School Psychologist: What else happens during the school day? He cries and wants to leave the classroom to call his mom. When I tell him to sit down, he says he is sick and needs to see the nurse. Instead of going to the nurse, he asks the secretary if he can to call his mother. Several observations of Paul s school arrival were conducted. When left at school by his mother, he was visibly distressed and crying. He routinely walked from the school parking lot to the playground, where he sat on the ground crying, while other students played. When Paul was interviewed he said, I miss my mom, and indicated he worried about not being with her. Diagnosis Paul, his parents, and his teacher were interested in reducing his apparent anxiety when he was left at school. In discussing possible treatment options with Paul, he said he cried because my mom leaves me, and that on the way to school, My chest feels puffy and I start crying. He also reported feeling lonely when dropped off at school. Based on Paul s self-report, the desires of his parents and teacher, and school observations, we identified anxiety manifested by crying as the behavior to be treated. A diagnosis of separation anxiety was established through behavioral observations and interviews with Paul, his teacher, and his mother. As he was displaying emotional difficulty at school, an assessment of his manifest behaviors was conducted at school. Other anxiety disorders (e.g., school phobia) were ruled out through observations of Paul s behaviors. For example, when dropped off at school he walked to the school building, did not voice concerns about going to school, and did not attempt to leave the school grounds. Paul displayed excessive anxiety due to being separated from his mother as he was left at school. He also repetitively voiced concerns about his mother s well-being. This behavior lasted longer than four weeks and restricted Paul s social interactions with other students. His behavior strained his relationship with his teacher as he disrupted other students by crying and making constant requests to call his mother. Due to these factors it was determined Paul s behavior met the diagnostic criteria for separation anxiety (American Psychiatric Association, 2001). Procedural Description Measurement To determine treatment efficacy, an A-B-C clinical research design was used. To establish inter-observer reliability, Paul s mother and teacher observed his behaviors during the baseline period. During the initial treatment condition, his behaviors were charted through teacher observation, parent observation, and self-report. In the second treatment condition and during the follow up period, his mother and teacher continued to observe Paul s behavior while his self-reporting was discontinued. The categories for the behavioral observations were mutually exclusive, and were intended to determine if Paul cried when his mother left him at school. Inter-observer agreement data on the occurrence of his crying was calculated by dividing the number of agreements by the number of agreements plus disagreements and multiplying by 100. The targeted behavior for observation was crying and inter-observer agreement was 100%. Treatment Paul s crying at school was actively treated over a 16-week period. To account for days not at school, five consecutive days was designated as a school week. Paul, his mother, and his teacher were the observers during the treatment. After a three-week baseline period, the initial treatment condition was implemented.

3 Treating Separation Anxiety Using Cognitive Behavioral Therapy 155 During the initial nine weeks of treatment two CBT techniques, self-charting and thought-stopping, were combined with antecedent control. For the self-charting, Paul was asked to record in a notebook daily if he cried after being left at school. To implement the thought stopping when he started to worry about his mother, Paul was taught to say no aloud, mentally throw the thought away, and to think of other things he could do instead of cry. This technique was explained to Paul in the following way: School Psychologist: What happens when your mom leaves you at school? I start to miss her and cry. School Psychologist: Would you like to try something that may help you stop crying? Yes School Psychologist: The first thing to do is write down the days when you cry. We can make a notebook calendar, and then every day you write down if you cried or not. Next is something called thought stopping. When you start to miss your mom, you say no out loud and throw that thought away. You could imagine you wrote it on a piece of paper, wadded it up, and then threw it away. After you say no, throw the thought away, and then think of doing something you like to do, like playing with your friends. OK Paul practiced these techniques until he understood what to do. The situation that prompted him to cry was then rehearsed in role plays in the school psychologist s office, then on the school parking lot and playground. When Paul s mother was asked what she told him when he got out of the car, she replied that she told him to have a good day. She was asked to tell Paul, I ll be here after school to pick you up, when he dropped him off at school. Thus, a cognitive based antecedent control technique in the form of verbal reassurance was incorporated into Paul s treatment. He also had weekly contact with the school psychologist to review his selfcharting notebook calendar and to role-play his thought stopping procedure during the initial treatment condition. After Paul stopped crying at school when he was dropped off by his mother, the same treatment condition was continued for four more weeks. His therapeutic regime was then modified to a maintenance period, continuing to include the thought stopping and antecedent control techniques. The self-charting and weekly visits with the school psychologist were discontinued. The second treatment condition was monitored for an additional four weeks, during which time Paul did not cry when his mother left him at school. Follow up observations were carried out for four weeks when school started the next year. Response to Treatment The results of this treatment are shown in Figure 1. During the baseline period, Paul cried each day during the first week and four out of five days during the second and third weeks. After the initial treatment condition, his crying occurred one day a week for the next four weeks. From the eighth week through the end of the second treatment condition, Paul did not cry at school when his mother dropped him off. After the end of the eighth week of treatment, he no longer met the diagnostic criteria for separation anxiety. At the start of the next school year, follow up observations found Paul did not cry when he was left at school. Conclusion The CBT techniques (i.e., self-charting, thought stopping, and antecedent control), in combination with parental involvement, were effective in eliminating Paul s separation anxiety, consistent with Howard and Kendall (1996). Paul was involved in setting his treatment goals and was actively involved in his treatment through self-charting. While this may seem like a minor point, adult clients are routinely involved in determining their treatment goals, and children deserve the same opportunity. Soliciting and obtaining Paul s input and seeking his agreement to the course of his treatment likely contributed to therapeutic success.

4 156 Treating Separation Anxiety Using Cognitive Behavioral Therapy Figure 1: Number of days/week Paul cried per week when left at school across baseline, initial treatment condition, second treatment condition, and one year follow up (SC = selfcharting, TS = thought stopping, and AC = antecedent control). This case was conducted at a public elementary school. The results indicate separation anxiety can be effectively treated within a school setting by school staff. From an ecological perspective, a key contributor to successful treatment is the involvement of others in the child s environment. Accordingly, it is important that the treatment regime be acceptable to the adults and practical to implement when treatment recommendations and interventions are not acceptable to the adults in a child s environment, they will not be implemented. This work shows the benefit of working to obtain the cooperation of adults in the child s life. The results also show the relevance of evaluating treatment outcome in the environment in which the problematic behavior occurs. After the second treatment condition, thought stopping and the antecedent control technique, was implemented, Paul s crying did not reappear during the therapeutic maintenance period. This suggests the combination of thought stopping and the verbal reassurance provided in the form of antecedent control were adequate to eliminate his targeted behavior, crying, when he was left at school. This combination of CBT techniques and parental involvement was easily implemented and can be applied in various environments. References American Psychiatric Association (2001). Diagnostic and statistical manual of mental disorders (4 th ed., Text Revision). Washington, DC: Author. Brückl, T. M., Wittchen, H. U., Höfler, M., Pfister, H., Schneider, S., & Lieb, R. (2007). Childhood separation anxiety and the risk of subsequent psychopathology: Results from a community study. Psychotherapy and Psychosomatics, 76, Eisen A. R., Raleigh, H., & Neuhoff C. C. (2008). The unique impact of parent training for separation anxiety disorder in children. Behavior Therapy, 39, Friman, P. C., Hayes, S. C., & Wilson, K. G. (1998). Why behavioral analysts should study emotion: The example of anxiety. Journal of Applied Behavioral Analysis, 31, Hanna, G. L., Fischer, D. J., & Fluent, T. E. (2006). Separation anxiety disorder and school refusal in children and adolescents. Pediatrics in Review, 6, Kendall, P. C., Flannery-Schroeder, E., Panichelli-Mindel, S.M., Southam-Gerow, M., Henin, A., & Warman, M. (1997). Therapy for youth with anxiety disorders: A second randomized clinical trial. Journal of Counseling and Clinical Psychology, 65, Pincus, D. B., Santucci, L. C., Ehrenreich, J. T., & Eyberg, S.M. (2008). The implementation of modified parent-child interaction therapy for youth with separation anxiety disorder. Cognitive and Behavioral Practice, 15, Ronen, T. (1996). Self-control exposure therapy for children s anxiety: A preliminary report. Child and Family Behavior Therapy, 18, 1-17.

5 Treating Separation Anxiety Using Cognitive Behavioral Therapy 157 Shear, K., Jin, R., Ruscio, A. M., Walters, E. E., & Kessler, R. C. (2006). Prevalence and correlates of estimated DSM-IV child and adult separation anxiety disorder in the national comorbidity survey replication. American Journal of Psychiatry, 65, Siqueland, L., & Diamond, G. (1998). Engaging parents in cognitive behavioral treatment for children with anxiety disorders. Cognitive and Behavioral Practice, 5, Vanderwerker, L., Jacobs, S. C., Parkes, C. M., & Prigerson, H. G. (2006). An exploration of associations between separation anxiety in childhood and complicated grief in later life. Journal of Nervous and Mental Disease, 194, Wood, J. J. (2006). Parent intrusiveness and children s separation anxiety in a clinical sample. Child Psychiatry and Human Development, 37,