Cognitive--Behavioral Therapy with a Six-Year-Old Boy with Separation Anxiety Disorder: A Case Study

Abstract

Cognitive-behavioral therapy (CBT) has become a respected and empirically established model of psychotherapy. A review of the experimental literature, by a task force established by the American Psychological Association, demonstrated the effectiveness of CBT for adults. In their review, CBT was efficacious for depression, generalized anxiety disorder, social phobia, obsessive compulsive disorder, substance abuse and dependence, agoraphobia, and panic disorder (DeRubeis & Crits-Christoph, 1998). Treating children with emotional and behavioral disorders using CBT has recently been receiving more research and clinical attention (Eisen, Kearney, & Schaefer, 1995; Jayson, Wood, Kroll, Fraser, & Harrington, 1998; Kendall, 1991; March & Mulle, 1998; Reincke, Ryan, & DuBois, 1998). The fundamental principles of CBT that apply to adult disorders can be applied to children, of course, with developmental modifications. Children, as well as adults, with psychological problems make systematic errors in thinking (cognitive distortions) and have skill deficits that maintain the problem (Kendall, 1991). The cognitive model hypothesizes that a person's thinking influences his or her mood and thus, modifications to thinking will result in changes in mood and behavior (Beck, Rush, Shaw, & Emery, 1979). This article is an exploratory study examining the use of cognitive--behavioral therapy in the treatment of separation anxiety disorder (SAD). The main clinical feature of this disorder is excessive worry about the separation from home or from the person to whom the affected person is attached (American Psychiatric Association [APA], 1994). The anxiety must be beyond what is expected for the developmental level and have been present for at least four weeks. Onset of the disorder must occur before 18 years of age. A child with SAD frequently reports fears that involve being kidnapped, becoming lost, or having his or her caretaker become hurt, killed, or kidnapped. When a child with SAD expects to be separated from his or her caretaker or when separation has just occurred, the child displays significant subjective distress. The child may cry, shake, express terror, and have autonomic symptoms of anxiety such as palpitations and hyperventilation (Black, 1995). The prevalence of SAD is estimated to be about 4 percent in children and young adolescents (APA, 1994). CONCEPTUALIZATION Separation anxiety disorder in children has similar clinical features as adults with panic disorder with agoraphobia, such as phobic avoidance, catastrophic interpretations, and panic symptoms. For example, a child with SAD tries to avoid separation from his or her caretaker (phobic avoidance), believes that if separated something terrible will happen and he or she will not be able to handle it (catastrophic interpretations), and experiences autonomic arousal such as palpitations, perspiration, hyperventilation, shaking, and fear (panic symptoms). A child with SAD makes catastrophic interpretations about being separated from his parents. This activates the child's autonomic nervous system, which creates anxiety symptoms, which then serve to reinforce the catastrophic interpretations. The cycle then becomes self-perpetuating. The treatment of panic disorder with agoraphobia in adults typically includes explanation of the nature of anxiety and panic, anxiety-management strategies (breathing, retraining, and relaxation), and cognitive restructuring (Barlow, Craske, Cerny, & Klosko, 1989; Otto & Deckersbach, 1998). Two new features to the treatment of panic by Craske, Meadows, and Barlow (1994) included prescriptive treatment for agoraphobia and the integration of a spouse or partner in exposure-based treatment. Barlow et al. (1989) found that about 90 percent of panic-disordered patients were panic free following their panic-control treatment. Previous treatment of children with SAD focused on medication and psychodynamic, family, or behavioral interventions (Drobes & Strauss, 1993; March, 1995). …