Separation Anxiety in Children and Adolescents: An Individualized Approach to Assessment and Treatment

320 Pages·2005·1.13 MB·English

by  Andrew R. Eisen PhD

SEPARATION ANXIETY
IN CHILDREN AND ADOLESCENTS

Separation Anxiety
in Children and Adolescents
AN INDIVIDUALIZED APPROACH
TO ASSESSMENT AND TREATMENT
ANDREW R. EISEN
CHARLES E. SCHAEFER
Foreword by David H. Barlow
THE GUILFORD PRESS
New York London
For Linda, Zachary, and Carly—continuous sources of inspiration
For Great Aunt Mumi
and in beloved memory of my Great Uncle Manny
For the charter members of my fan club
—A.R.E.
For my family—Anne, Karine, and Eric—
for their unwavering love and support
—C.E.S.
©2005TheGuilfordPress
ADivisionofGuilfordPublications,Inc.
72SpringStreet,NewYork,NY10012
www.guilford.com
Allrightsreserved
Exceptasindicated,nopartofthisbookmaybereproduced,translated,storedina
retrievalsystem,ortransmitted,inanyformorbyanymeans,electronic,mechanical,
photocopying,microfilming,recording,orotherwise,withoutwrittenpermissionfrom
thePublisher.
PrintedintheUnitedStatesofAmerica
Thisbookisprintedonacid-freepaper.
Lastdigitisprintnumber: 9 8 7 6 5 4 3 2 1
LIMITEDPHOTOCOPYLICENSE
Thesematerialsareintendedforuseonlybyqualifiedmentalhealthprofessionals.
Nonassignablepermissiontoreproducetheappendicesisgrantedtoindividualpurchas-
ersofthisbook.Thislicenseislimitedtoyou,theindividualpurchaser,forusewithyour
ownclientsandpatients.Itdoesnotextendtoadditionalcliniciansorpracticesettings,
nordoespurchasebyaninstitutionconstituteasitelicense.Thislicensedoesnotgrant
the right to reproduce these materials for resale, redistribution, or any other purposes
(includingbutnotlimitedtobooks,pamphlets,articles,video-oraudiotapes,andhand-
outs or slides for lectures or workshops). Permission to reproduce these materials for
theseandanyotherpurposesmustbeobtainedinwritingfromthePermissionsDepart-
mentofGuilfordPublications.
LibraryofCongressCataloging-in-PublicationData
Eisen,AndrewR.
Separationanxietyinchildrenandadolescents:anindividualizedapproachtoassessment
andtreatment/byAndrewR.Eisen,CharlesE.Schaefer.
p.cm.
Includesbibliographicalreferencesandindex.
ISBN1-59385-131-6(hardcover:alk.paper)
1. Separationanxietyinchildren. 2. Separationanxietyinadolescence. 3. Parentand
child. I. Schaefer,CharlesE. II. Title.
RJ506.S46E372005
618.92′8522—dc22
2004026091
About the Authors
AndrewR.Eisen,PhD,isAssociateProfessorintheSchoolofPsychol-
ogy/Sociology and Director of the Child Anxiety Disorders Clinic
at Fairleigh Dickinson University. His research and clinical interests
include childhood anxiety and related problems, nonverbal learning
disorders,andsensoryintegrationissues.Dr.EiseniscoauthorofPrac-
titioner’sGuidetoTreatingFearandAnxietyinChildrenandAdolescents:A
Cognitive-Behavioral Approach (1995, Jason Aronson) and coeditor of
Clinical Handbook of Anxiety Disorders in Children and Adolescents (1995,
JasonAronson).Healsohasprivatepracticesfocusingonchildrenand
families in Bergen County, New Jersey, and in Rockland County, New
York.
Charles E. Schaefer, PhD, is Professor of Clinical Psychology at
Fairleigh Dickinson University. He is also Director Emeritus of the
International Association of Play Therapy and has coauthored or
coeditedmorethan50booksonchildtherapy,playtherapy,andeffec-
tive parenting, including Short-Term Play Therapy for Children (2000,
Guilford Press). In addition, Dr. Schaefer maintains a private practice
in child psychology in Hackensack, New Jersey.
v

Foreword
It was not until the 1960s that psychotherapy began to deviate from a
common and relatively uniform approach to treating psychopathology
by tailoring treatments to specific psychological problems. Until that
time the nature of psychopathology was ill defined and played little
role in treatment planning. This changed rather dramatically during
the1970sand1980s,beginningwiththetreatmentofanxietydisorders
and spreading across the full range of psychopathology as these prob-
lems became better delineated. It was, perhaps, DSM-III that first
defined these concepts in enough detail to spark more broad-based
attempts at designing treatments, both psychological and pharmaco-
logical,thatwouldbeespeciallyeffectiveinaddressingthepsychopath-
ology at hand (Barlow, 1988). Ironically, the trend in the specification
oftreatmentswasmoreobservableforwhatsomearenowcalling“psy-
chological treatments” (Barlow, in press) than for pharmacological
treatments as individual treatment protocols appeared during the
1980sand1990sforeachofthedisordersfirstarticulatedinDSM-III.
This trend began with Wolpe’s (1958) description of systematic
desensitization and continued in the 1970s with detailed descriptions
of exposure-based treatments (Agras, Leitenberg, & Barlow, 1968;
Marks, 1971). Systematic desensitization in particular sparked a flurry
of research aimed at dismantling the effective ingredients in this well-
operationalized procedure, and assessing with ever more precise mea-
surestheoutcomesofthistreatment.Thisinturnallowedpsychothera-
py investigators to begin refocusing research from an emphasis largely
on process to one on outcomes (Barlow & Hersen, 1984; Hersen &
Barlow, 1976). These developments resulted in a very healthy process
vii
viii Foreword
in which theories of mechanisms of action in psychotherapy could be
directly tested and modified or discarded in favor of more parsimoni-
ous and productive theories (Barlow, 1988). In this way, our science
and practice began to complement one another in an iterative process
resulting in newer and more effective treatments.
At the same time, great strides were occurring in our understand-
ingofthenatureofpsychologicaldisordersthat,inturn,ledtorefine-
ments in our treatment procedures. For example, one controversy in
the early 1970s, referred to in the pages that follow in this book,
explored the functional relationship of anxious behavior upon separa-
tionfromparentsinyoungchildren.Oneearlystudyclearlydelineated
thatthebehaviorofanxiousseparationcouldbeafunctionofverydif-
ferent circumstances. For example, some young children might envi-
sion substantial harm coming to their parents or themselves during
separation,whichcouldbethefocusofintenseanxiety.Otherchildren,
upon careful analysis, were not actually anxious about separating per
se,butfoundtheschoolsituationinallitscomplexitytobeparticularly
anxietyprovoking(Lazarus,Davison,&Polefka,1965).Thisisnotsur-
prising in retrospect, but it was considered a very clever analysis at the
time, which led directly to differential treatment planning.
It was this type of discovery in the clinical arena, as well as more
basic phenomenological or phenotypical observations on presenting
symptoms, onset, course, and response to treatment, that led to ever
greater delineation and demarcation in our nosology, a tendency
known as “splitting.” Indeed, most investigators would agree that the
field reached the zenith of splitting with the publication of the fourth
edition of the Diagnostic and Statistical Manual of Mental Disorders
(American Psychiatric Association, 1994) and its emphasis on reliably
identified but very narrow slices of psychopathology resulting in
numerous disorders (Brown & Barlow, 2002). More recently, experi-
mentalpsychopathologists,nosologists,andtherapyoutcomeresearch-
ers have begun to converge on a new conception of psychopathology
thatemphasizescommonalitiesratherthandifferences.Thisisparticu-
larly true in the emotional disorders, of which separation anxiety dis-
order is one. These new arguments point to findings reflecting
substantial comorbidity among the emotional disorders as well as
phenotypic similarity. Additionally, investigators have observed wide-
rangingeffectsoftreatmentsthatweredesignedforspecificdisorders,
such as phobia or depression, on accompanying comorbid emotional
disorders where the therapeutic results are often as good as for the
principal disorder. This indicates a possible nonspecificity of treat-
ment, both psychological and pharmacological. Also underscoring
Foreword ix
commonalities among these disorders is emerging research on the
latent structure of dimensional features of emotional disorders.
More recently, reflecting many of these developments from basic
neuroscience to treatment outcome, we have proposed a theory of the
etiology of emotional disorders referred to as “triple vulnerabilities”
(Barlow,1991,2000,2002),explicatedinsomedetailinthisbook.The
triple vulnerability theory encompasses a generalized biological vul-
nerabilitysometimesreferredtoas“temperament.”Thisbiologicalvul-
nerability involves nonspecific genetic contributions to the develop-
ment of anxiety and negative affect. In the anxiety disorders, research
has focused on such concepts as “anxiety,” “neuroticism,” “negative
affect,” or, particularly in the case of children, “behavioral inhibition.”
While each of these concepts has generated somewhat independent
bodiesofresearch,itisverylikelythateachconceptistapping,atleast
partially,acommonthemeassociatedwithabiologicalvulnerabilityto
developing emotional disorders generally.
Asecondvulnerability,referredtoasa“generalizedpsychological
vulnerability,” comprises early-life experiences, often but not always
traumatic or disruptive, that produce a sense of uncontrollability over
important environmental events. This sense of uncontrollability seems
to be at the core of negative affect and the derivative states of anxiety
and depression (Barlow, 2002). Once again, a robust line of research
from a variety of species, including humans, supports the salience of
certain early-life experiences in shaping our views of the world or pro-
viding a filter for our experience. These two vulnerabilities alone, if
theyoccurtogether,arelikelytoproduceagenerallyanxiousordepres-
sive temperament if triggered by life events that may first manifest as
separationanxietyand,later,asgeneralizedanxietydisorderordepres-
sive disorders. A third vulnerability, referred to as a “specific psycho-
logical vulnerability,” is also a function of early experience, such as
modeling from parents, and serves to focus anxiety on specific objects
or situations, such as learning that certain animals or insects, certain
somatic sensations, or social evaluations, are dangerous. The develop-
ment and interaction of these diatheses has been outlined in some
detail elsewhere (Barlow, 2002; Bouton, Mineka, & Barlow, 2001).
What is important for the purposes of this book is that we are becom-
ing more sophisticated in our understanding of the nature of psycho-
pathology, allowing the development of more powerful and important
treatmentsasdescribedinthisoutstandingneweffortfromAndrewR.
Eisen and Charles E. Schaefer.
Theageofevidence-basedtreatmentsisuponus.Recently,govern-
ments and health care policymakers around the world have decided
x Foreword
that many psychological treatments have evidence that is more than
sufficient for inclusion in health care systems. This is very important
because organized health care systems, faced with inadequate health
care and spiraling costs, have decided that the quality of health care
should improve, that it should be evidence-based, and that it is in the
publicinteresttoensurethatthishappens(Barlow,inpress;Instituteof
Medicine, 2001). Of course, our treatments, while demonstrably effec-
tive based on all the current rules of evidence, are far from perfect.
Many individuals suffering from emotional disorders at clinically sig-
nificant levels either fail to benefit from our treatments or improve
only partially. Thus, we need a great deal more evidence on patient–
treatment matching and on generalizing or translating robust results
from psychological laboratories and clinics to the front lines where
most clinical care is delivered.
It is also crucial that we develop more concerted efforts focused
on early intervention and prevention. In this regard, as Eisen and
Schaefer point out, separation anxiety has been considered in the
past to be a risk factor for the later development of emotional disor-
ders in adolescence and adulthood. This view is now not as popular
as it once was, since it is very likely that separation anxiety is simply
an early manifestation of the diatheses described previously, and that
separation anxiety does not occur only in childhood, but can occur
in adolescence and even in adulthood. Nevertheless, our best evi-
dence is that early intervention with anxious or depressed children is
not only effective but may introduce resilience to the development of
later emotional disorders. For these reasons, the program developed
by Eisen and Schaefer is particularly noteworthy in that important
preventive purposes might be served in addition to the relief of cur-
rent suffering.
In this age of evidence-based care, Eisen and Schaefer have devel-
oped a state-of-the-art, evidence-based treatment program for separa-
tion anxiety that draws not only on the latest thinking from the lab-
oratories of cognitive and behavioral science but also on recent
trendsinresearchthatemphasizeprescriptiveapproachesandpatient–
treatment matching. These clinicians and scientists, experts in both
fields, draw on years of experience to produce a treatment program
that should bring us to the next level of clinical care for this very dis-
tressed population of children and their parents.
DAVID H. BARLOW, PhD
Director, Center for Anxiety and Related Disorders
Boston University