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Cognitive Behavioural Intervention for Separation Anxiety Disorder in a Child with Mild

Cognitive Delay

Name: F.G.

Age: 10 years

Gender: Female

Source of Referral: Staff Specialist

Reason for Referral: Assessment and intervention for anxiety

Setting: Hospital outpatient rehabilitation programme

1 Brief History of the Presenting Problem

On initial presentation, F.G.s mother (K.G.) reported that F.G. had been experiencing

sleep difficulties since the age of 2. She described a history of experiencing difficulties with

falling and staying asleep, nightmares, needing to sleep with the light on, trying to keep

herself awake, and refusing to sleep in a room on her own. As further inquiry progressed, it

became apparent that F.G. would become very distress in many situations that required

separation from her mother including sleeping at a friends house, being alone, and entering

dark rooms. F.G. reported that she frequently worried that something bad would happen to

her or a family member when they were separated and she would frequently became

distressed when her parents went out without her. She also experienced a number of

generalised concerns including being embarrassed, feeling sick, and being late. It was agreed

that the focus of treatment would be F.G.s separation anxiety.

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2 Medical and Psychological History

F.G. presented with a medical history of Spina Bifida, shunted hydrocephalus and

neurogenic bladder and bowl. Neuropsychological assessments performed in 2006 and

2008 revealed that F.G. had a mild intellectual delay. Regular medical follow up in regards to

her medical conditions was conducted at the hospital to monitor F.G.s progress and

development.

3 Details of Assessment

Clinical Interview: Clinical interviews to gather a history of the presenting problems

and background information were conducted with both F.G. and K.G. During assessment,

F.G. was observed to be embarrassed to discuss her worries but on prompting and

encouragement would verbalise her worries and associated feelings.

Anxiety Disorders Interview Schedule IV Child/Parent Version (ADIS-IV:C/P;

Silverman & Albano, 1996): The ADIS-IV:C/P is a semistructured interview aimed at assisting

clinicians to diagnose DSM-IV-TR emotional disorders where anxiety is a prominent

component. It consists of both a child and parent interview schedule. This was administered

to both F.G. and to K.G. as part of the initial assessment phase.

Revised Child Anxiety and Depression Scales (RCADS; Chorpita, Yim, Moffitt,

Umemoto, & Francis, 2000). The RCADS is a self-report inventory consisting of 47 items

assessing symptoms of DSM-defined anxiety disorders and major depressive disorder. Items

are rated on 4-point scale to give subscale scores for each disorder and a total anxiety score.

Clinical cut-off scores are also available to assist with diagnosis. This was administered as an

outcome measure pre- and post-treatment.

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4 Diagnosis

Primary Diagnosis

Based on the clinical interview, and results of the ADIS-IV:C/P and RCADS , it was

evident that F.G. met full diagnostic criteria for Separation Anxiety Disorder (SAD), Early

Onset (309.21; American Psychiatric Association (APA), 2000). F.G. demonstrated

developmentally inappropriate and excessive anxiety upon separation from her mother

evidenced by excessive distress upon anticipated and actual separation, persistent and

excessive worry about harm to her parents and her brother, reluctance to be alone at home

or at a friends house without her mother, refusal to sleep alone, and nightmares involving

separation from key family figures (Criterion A). These difficulties had been chronic for F.G.,

beginning at approximately the age of 2 (Criterion B and C) and were causing significant

impairment in F.G.s social and family life (Criterion D). Criterion E was also met as F.G. did

not present with either a pervasive developmental disorder or a psychotic disorder.

Comorbid Diagnosis

F.G. was determined to have a comorbid diagnosis of a Specific Phobia for a fear of

the dark (300.29; APA, 2000). It is likely that F.G.s fear of the dark developed from her

primary diagnosis of SAD and was strongly related to this as her fears were largely present

at bed time, which coincided with separation from her mother. This is consistent with

research findings that children with SAD often present with specific fears that have

developed to phobic proportion following the development of SAD (Last, 1989).

Differential Diagnosis

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F.G. exhibited some features of Generalised Anxiety Disorder (GAD) (300.02; APA,

2000) including excessive worry about a number of events (Criterion A), difficulty controlling

the worry (Criterion B), and difficulty falling asleep (Criterion C). F.G., however did not

report experiencing any other physical symptoms indicated in the diagnostic criteria.

Conceptually her difficulty falling asleep may be better accounted for by the diagnosis of

SAD, suggesting clinical diagnosis may not be reached. In addition, scores on the RCADS

indicated a high but not clinical level of GAD.

5 Cognitive Behavioural Formulation

A number of vulnerability factors were hypothesised to explain the development of

F.G.s anxiety. In particular, F.G.s family were socially isolated due to F.G.s father speaking

limited English and primarily engaging with extended family. F.G. had also experienced a

number of stressful hospital visits due to her medical condition and underwent daily

catheterisations and bowel washouts that were distressing for her and placed her family

under significant stress. F.G.s long history of avoiding anxiety-inducing situations was

consistent with a temperament lending itself to engaging in behavioural inhibition. K.G. also

also reported a history of undiagnosed parental anxiety. All of these factors have been

associated with increased risk for the development of childhood anxiety disorders (Klein &

Pine, 2002; Ginsburg, Siqueland, Masia-Warner, & Hedtke, 2004)

The tripartite model of anxiety suggests that anxiety is triggered and maintained by

behavioural, physiological and cognitive components (Strauss & Todaro, 2001). In terms of

the behavioural component, F.G. appeared to engage in a substantial degree of behavioural

avoidance (e.g. refusing to sleep alone, not going to friends houses). From an operant

conditioning perspective, these behaviours were reinforced through anxiety-enhancing

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parenting behaviours such as K.G. allowing F.G. to sleep in the same room as another family

member, and through another family member consistently accompanying F.G. to rooms in

the house she was afraid to enter. F.G. also received a significant amount of attention from

K.G. and other family members in regards to her reluctance to be alone. This pattern of

avoidance and attention is suggested to have provided short term reductions in her anxiety

symptoms, however over time this is likely to have maintained and exacerbated her anxiety.

F.G. initially did not report any physiological symptomatology in regards to her

anxiety, however during the third session she reported experiencing a number of somatic

complaints consistent with anxiety. She indicated that when confronted with anxiety

provoking situations, she would feel butterflies in her stomach, tingling in her legs, heavy

hands and feet, sweating, and dry lips. These uncomfortable physical sensations appeared

to influence F.G.s behavioural avoidance and were likely affected by a pattern of cognitive

distortions.

F.G. appeared to engage in cognitive distortions around the meaning and

consequences of being alone. From the interview with herself and K.G. it appeared that F.G.

would catastrophise that something bad would happen to her or another family member

if they were separated (e.g. someone would break into the house through the bathroom

window if she was left alone). These distortions are consistent with the tendency that

anxious individuals have to exaggerate levels of threat, danger, and fear (Beck & Emery,

1985). F.G.s cognitive distortions appeared to exacerbate her symptoms of anxiety and to

have maintained them through a poor ability to identify and challenge these thoughts.

Thus, her cognitions are likely to have contributed to an ongoing spiral of increased

physiological arousal and behavioural avoidance leading to chronic fears around separation.

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Positive prognostic factors for F.G.s treatment were indicated by K.G.s commitment

to therapy, and to utilising strategies learned in session at home. Particular difficulty was

expected with engaging F.G. in cognitive work due to her mild intellectual delay and

evidenced difficulty with identifying cognitions during the assessment phase. Treatment

outcomes were also expected to be limited due to time constraints placed on the length of

therapy.

6 Description of the Treatment Plan, Components and Implementation

The efficacy of CBT in treating childhood anxiety disorders has been well

documented within the research literature. A number of randomized control trials have

indicated that treatment using CBT is more efficacious than wait-list control, placebo

conditions, and active controls (Barrett, Dadds & Rapee, 1996; Hudson, Rapee, Deveney,

Schniering, Lyneham, & Bovopoulos, 2009; Kendall, 1994; Walkup, Albano, Piacentini,

Birmaher, Compton, Sherrill et al., 2008). Core to CBT for SAD (and other childhood anxiety

disorders) is an emphasis on teaching children to recognise and manage unwanted anxiety

using cognitive and behavioural strategies, and to apply these skills to real-life situations.

The main components of treatment that have been demonstrated as effective in the

research literature were implemented for F.G., however these were delivered in a

compressed format as F.G. was able to attend only a total of 5 sessions. The components

delivered included: 1) identifying and modifying maladaptive cognitions; 2) developing

coping strategies such as coping self-statements and relaxation skills; 3) gradual exposure to

anxiety-inducing stimuli; and 4) contingency management (Labellarte et al., 1999; Suveg,

Comer, Furr, & Kendall, 2006). These components of treatment were aimed at targeting the

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maintaining factors of anxiety including maladaptive thinking patterns, avoidance of feared

situations and/or stimuli, and behavioural reinforcement of avoidance behaviours.

One of the expected difficulties with treatment for F.G. was her impaired cognitive

functioning and hence ability to engage in cognitive strategies as a part of treatment. For

children with intellectual impairment, there is some indication that they experience

difficulty with the cognitive component of treatment due to impaired metacognitive and

perspective-taking skills (Weisz & Weesing, 1999; Suveg et al., 2006). A focus on behavioural

strategies and concrete therapeutic processes has been suggested to be beneficial in

addressing these difficulties (Ciechomski, Jackson, Tonge, King, & Heyne, 2001; Suveg et al.,

2006). When it became apparent in Session 3 that F.G. was having difficulty with identifying

and challenging her maladaptive cognitions, concrete behavioural strategies were focused

on to assist F.G. with learning concepts and addressing her anxiety similar to those utilised

by Suveg et al. (2006).

Parent training was also included to allow K.G. to become the therapist-at-home

and to introduce behavioural reinforcement of F.G.s brave behaviour to encourage this

desirable behaviour and reward her progress. The addition of parent training to CBT for

children has been demonstrated to be more effective than CBT alone in the treatment of

childhood anxiety disorders both at post-treatment and up to 3 years later (Barrett et al.,

1996; Cobham, Dadds, Spence, & McDermott, 2010; Labellarte, Ginsburg, Walkup, & Riddle,

1999). Aspects of parent training included psychoeducation about anxiety and the different

components of treatment, training in contingency management, and providing

opportunities to demonstrate modelling and reinforcement of brave behaviours within

session that K.G. could apply at home.

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7 Summary of Sessions

Session Intervention

1 (1hr) Clinical Interview with K.G.

2 (1.5hrs) Clinical Interview with F.G. and administration of ADIS-IV:C/P to F.G.

and K.G., and RCADS to F.G.

3 (1.5hrs) Psychoeducation about anxiety and contingency management (K.G.)

Identifying feelings, maladaptive cognitions, and self-rewards (F.G.)

4 (1.5hrs) Review homework

Behavioural coping strategies (deep breathing, progressive muscle

relaxation) and development of exposure hierarchy (F.G.)

Psychoeducation on maintenance of anxiety, role of attention and

reinforcement, and gradual exposure (K.G.)

5 (1.5hrs) Review homework

Preparation for addressing next step in exposure hierarchy (F.G.)

Administration of post-treatment RCADS (F.G.)

Address difficulties with utilising contingency management (K.G.)

8 Treatment Progress

Due to F.G.s difficult with grasping cognitive and abstract concepts, progress and

depth of therapy was slower than would be normally anticipated. Despite this, F.G. was

observed to improve her ability to recognise and label emotions, identify the link between

thoughts, feelings and behaviours, and engage in brave behaviours in session. The use of

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repetition and simplifying concepts was particular useful for F.G. to grasps tasks given in

therapy. Concrete behavioural activities (adapted from Suveg et al., 2006) as well as

labelled praise were very useful to encourage non-anxious behaviours. Results of the post-

treatment RCADS indicated that F.G. was still presenting within the clinical range for

separation anxiety disorder. Treatment concluded with the family being aware of the need

for ongoing treatment due to the persistence of F.G.s anxiety, and the chronicity of F.G.s

presenting problems.

9 Conclusions & Reflections

This case presented a number of therapeutic difficulties including the limitations on

using cognitive interventions and the limitations to the length of therapy. Possible reasons

for the lack of significant improvement include the short length of treatment (researched

treatments are typically 10-16weeks; Labellarte, 1999) resulting in insufficient completion of

the treatment components and difficulties with K.G. implementing contingency

management. If more sessions were available for treatment, it would have been beneficial

to have spent a greater amount of time teaching F.G. and K.G. the treatment components

(in particular gradual exposure and more in-depth parent training) to solidify learning,

generalise the use of skills to address F.G.s specific phobia and symptoms of GAD, and

ensure that skills were being appropriately implemented at home. Greater emphasis and

time spent utilising concrete behavioural strategies may also have been beneficial along

with sleep management strategies to address F.G.s sleep difficulties.

F.G.s case presented a unique challenge to my own clinical skills in being able to

adapt to the clients needs and implement the core strategies that the family would be able

to learn and implement after therapy finished. While my clinical skills in adapting and

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modifying therapy within a medical context improved from working with this family, my

clinical skills would benefit from further development in utilising behavioural and creative

techniques to engage and work with children to meet their developmental stages and

cognitive capacities. Further experience and supervision around engaging parents in

therapy would also be beneficial as working with parents parenting beliefs and motivation

for change presents a unique challenge in itself.

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