Psychology

In 2001 David Dia had an article published entitled, Cognitive-Behavioral Therapy with a Six-year Old boy with Separation Anxiety Disorder A Case Study.  It was published in the Health and Social Work Journal.  This insightful article focused on the use of Cognitive-Behavioral Therapy (CBT) in children and adolescents with Separation Anxiety Disorder (SAD).  Dia hypothesized that the fundamentals of CBT in adults could be modified and applied to treating small children and adolescents.  Dia based this hypothesis was on the previous theory maintaining that the cognitive behavior model hypothesizes that ones thinking influences the mood, therefore requiring changes in thinking will modify behavior and mood (Beck, Rush, Shaw,  Emery, 1979).  In children, SAD is distinguished by excessive worry about being separated from a parent or caretaker or from home in a way that creates excessive worry and distress for the patient affected (American Psychiatric Association APA, 1994).  The article gives the background of the child affected with SAD, clinical assessment, treatment plan, treatment history, and a final analysis of the case study.

The article begins with a brief background of the subject.  The subject is a six-year old, first grade, boy named Colt.  Colt suffers from panic attacks due to separation issues concerning his parents.  If his mother goes upstairs in their family home, Colt will experience a panic attack.  Colt is reported to have at least one panic attack per day.  The subject refuses to leave home without his mother or father accompanying him, and when he is in public with his parents, he is reported to be excessively clingy.  After a psychological assessment by Dia, the subject was diagnosed with SAD and Attention Deficit Hyperactivity Disorder-inattentive type according to the diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders-IV (APA, 1994).  According to the APA, SAD affects 4 of children and young adolescents.
                                                                                                                         
One problem was evident with this article.  It was only one case study.  Despite the fact that the result was found to be positive, it would have carried more weight if the study had included more than one child with SAD.  There are many factors to be considered when dealing with childhood mental disorders.  Demographics, family dynamics, learning disabilities, and the possible existence of a co-morbid condition are just a few of the significant factors to be considered.  Aside from this area of concern, the article was very forthright and accurate in validating the research and method used.
   
SAD typically affects children and adolescents before the age of eighteen.  Patients with SAD display fear of being lost or kidnapped and fears that a serious injury or death will happen to their parent or caregiver.  Upon being separated from home, a parent, or a caregiver the patient will sometimes shake, cry, express terror, experience heart palpitations, and sometimes hyperventilate (Dia, 2001).  Past treatments for SAD included medication and psychodynamic, family, and behavioral therapies.  Currently, research is being conducted to determine the effectiveness of CBT in treating children and adolescents with SAD.  Dia emphasizes that CBT in treating SAD reduces the patients reliance on medication because of two reasons.  The first reason is because the role and impact of the caretaker is addressed in therapy, and secondly because cognitive distortions are addressed via evidence based analysis.
   
The case study from the article introduced a four-phase process used in CBT for treating SAD in children and adolescents (Dia, 2001).  Phase I provides psychological education for the parent or caregiver in reference to the patients diagnosis as it relates to the cognitive model.  Phase II focuses on the development of coping strategies that will aid the patients cognitive behavior.

Phase III uses graded exposures to re-program the patients thought and feeling methods.  Finally, Phase IV is simply a booster session.
   
Colt was treated using the four-phase CBT process to treat his SAD.  Dia introduced Phase I to Colt and his parents by explaining what a diagnosis of SAD and ADHD means, what it is, and how to effectively deal with it.  Reading materials were provided to the parents to take home.  Dia used age appropriate stories to explain the diagnosis to Colt.  Focus was then put onto teaching Colt how to recognize and label his thoughts and feelings.  Phase II and Phase III were integrated by combining the coping strategies with graded exposures.  Dia was able to effectively teach Colt how to cope by developing a trusting therapist-to-patient relationship.  Once this was established, Dia used contingency management, distractions, self-statements, and full exposures to complete Phase III of the CBT process.  Contingency management was handled by using a chip system whereby Colt was rewarded for trying and coping successfully.  The distractions consisted of relaxation techniques to be used when feelings of anxiety began to build.  These techniques included counting exercises and an ABC game.  Self-statements were used to build Colts self-esteem.  These statements included positive phrases referring to personal bravery and positive self-reinforcement.  The full exposure portion began with Colt remaining in a room while his parents stepped outside.  Gradually, Colts coping cognitive behavioral skills built enough to allow his parents to even leave the building for lengths of time.  Finally, the booster session, or Phase IV, is demonstrative by reviewing the strategies used, giving Colt credit for his success and building up his self-esteem, and addressing any issues of relapse (Dia, 2001).
   
Dia concluded this case study by indicating that the modification of CBT for a child or adolescent can work to treat SAD.  He indicated that the subject of his case study, Colt, who had initially been experiencing one panic attack per day, was now reported to only have had two panic attacks over a four month period post-CBT.  Dia emphasized the importance of the familial influence during the CBT process because the family spends the majority of its time with the patient.  There is certainly no doubt that CBT shows promise for children and adolescents with SAD, but as Dia indicated, more research is needed in order to validate his findings.  A larger study following this method would be highly recommended.  If performed on a larger scale, a more diverse group of children and adolescents could be tested to include children and adolescents of single parents, older children, and even younger children.  This proposed study should also address cultural and social issues and how they affect a child or adolescent with SAD who is treated with CBT.
   
As a guidance counselor, this information is increasingly important as an academic setting often is exposed to problematic behaviors of children and adolescent behaviors sometimes before the family takes notice.  The academic institution in some instances must notify the parents or caregiver of the noticed behaviors and make suggestions for psychological intervention.  Some parents and caregivers become aversive in their views of the child and pass off the behaviors as a phase.  Other parents or caregivers become overprotective of the child and take the notification of problematic behavior as a personal criticism or as a biased opinion of the child.  School systems should allow for training to all faculty and staff in relation to new therapeutic techniques being implemented as a means of strengthening the academic institutions knowledge for recognizing potential problems.
   
Ultimately, the article was well written, concise, and to-the-point.  If the article had included more case studies, it would have been much more effective and convincing.  The fact that CBT had a positive impact on Colt is a wonderful and positive thing, but the question still remains as to whether or not CBT will work on the majority of children with SAD.  SAD is a difficult condition for the child or adolescent that it affects.  It can almost render a child or adolescent unable to function, especially if the child cannot leave the family home due to fears and anxiety.  Psychologists, guidance counselors, therapists, and family physicians must work together to do more research in this area of CBT.  The modified CBT seems to hold much promise for children and adolescents with anxiety disorders.  It is most promising to know that if the child or adolescent is able to benefit from CBT now, then as they grow and mature into adulthood, the likelihood of them developing generalized panic disorder will be greatly reduced.  It would seem that the benefits of CBT far supersede any potential risk involved.  Fortunately, there is no risk.