ICL 3.2: Recognizing/Treating Childhood Disorders

Question 1

what is separation anxiety disorder?

Answer 1

separation anxiety is a typical developmental phenomenon first appearing in infants < 1 year of age and marking awareness of separation from caregiver

the expression of some separation anxiety is also normal for young children entering school for the first time, among infants and toddlers

however, it’s NOT normal for older children and adolescents and may be indicative of Separation Anxiety Disorder

Question 2

what are the DSM5 criteria for diagnosing separation anxiety disorder?

Answer 2

the anxiety or fear must cause distress or affect social, academic, or job functioning and must last at least 4 weeks

developmentally inappropriate and excessive or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three or more of the following:

1. recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures
2. persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death
3. persistent and excessive worry about experiencing an untoward event like getting lost, being kidnapped, or becoming ill that causes separation from a major attachment figure
4. persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation
5. persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings
6. persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure
7. repeated nightmares involving the theme of separation
8. repeated complaints of physical symptoms such as headaches, stomachaches, nausea, or vomiting when separation from major attachment figures occurs or is anticipated

Question 3

what is the clinical presentation of someone with separation anxiety disorder?

Answer 3

1. feel unsafe staying in a room by themselves
2. display clinging behavior
3. display excessive worry and fear about parents or about harm to themselves
4. shadow the mother or father around the house
5. have difficulty going to sleep*
6. have nightmares
7. have exaggerated, unrealistic fears of animals, monster, burglars
8. fear being alone in the dark
9. have severe tantrums when forced to go to school*

Question 4

children with separation anxiety disorder are more at risk for what conditions?

Answer 4

1. GAD = generalized anxiety disorder
2. panic disorders
3. agoraphobia
4. full-blown school phobia

symptoms of depression, such as sadness, withdrawal, apathy, or difficulty in concentrating are also common with SAD

Question 5

what is the distinguishing feature of SAD in comparison with other anxiety disorders?

Answer 5

the distinguishing feature of SAD is fear related to separation experiences

with other anxiety disorders, the presence of an attachment figure has little impact on the fear; a parent being around won’t reduce anxiety but kids with separation anxiety are soothed by their parents and by being at home with them

Question 6

what is the prevalence of separation anxiety disorder?

Answer 6

4% of school-aged children

1.6% of adolescents

most commonly seen in 7-to-8 year old children

it’s the most common anxiety disorder in youth under 12 years old

may be over-diagnosed in youth who live in dangerous neighborhoods and have reasonable fears of leaving home

Question 7

is SAD more prevalent with boys or girls?

Answer 7

studies indicate that disorder is more common in girls, but both boys and girls seek treatment at equal rates

girls show more school avoidance

boys show less independence in their play or activities and more reluctance to be away from home alone

Question 8

what is the genetic association with SAD?

Answer 8

SAD sometimes runs in families, but the precise role of genetic and environmental factors has not been established

Question 9

what are the risk factors for developing separation anxiety disorder?

Answer 9

1. affected youth tend to have very close-knit families and parental overprotection/enmeshment is often a factor
2. disorder most likely to develop after a significant stressor like death/illness in the family, parental divorce, moving to a new house/school, trauma (physical or sexual)

Question 10

how do you treat separation anxiety disorder?

Answer 10

1. multimodal treatment

2. cognitive behavioral therapy

Question 11

what is multimodal treatment for SAD?

Answer 11

1. cognitive behavioral therapy
2. family education/ family therapy –> fix the parent’s behavior that’s teaching the kids that the world is dangerous or being anxious themselves; don’t let their kids avoid all their anxiety tics
3. pharmacological interventions are used when additional strategies are needed to control the symptoms

Question 12

what is cognitive behavioral therapy for SAD?

Answer 12

1. short term therapy: 6-20 sessions
2. focus is on teaching youth on how their thoughts, feelings and behaviors are interconnected and impact each other
3. teaching various skills like relaxation, challenging negative/fearful thoughts, promoting positive behaviors/coping skills
4. parents are incorporated into sessions to help reinforce skills through homework at home
5. goals include keeping/getting child in school

Question 13

what is the DSM5 criteria for reactive attachment disorder?

Answer 13

1. a consistent pattern of inhibited emotionally withdrawn behavior toward adult caregivers: (1) the child rarely or minimally seeks comfort when distressed (2) the child rarely or minimally responds to comfort when distressed
2. a persistent social and emotional disturbance characterized by: (1) minimal social and emotional responsiveness to others (2) limited positive affect (3) episodes of unexplained irritability, sadness or fearfulness that are evident even during nonthreatening interactions with adult caregivers
3. the child has experienced a pattern of extremes of insufficient care as evident by at least one of the following: (1) social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults (2) repeated changes of primary caregivers that limit opportunities to form stable attachments (3) rearing in unusual settings that severely limit opportunities to form selective attachments

Question 14

what is reactive attachment disorder?

Answer 14

insufficient care causes the emotional and behavioral disturbances in kids –> the kids have no emotional connection with their caregivers so no social referencing, no separation anxiety, etc.

super prone to giant meltdowns over the smallest things and shows of aggression

the disturbance is evident before age 5 years and child has a developmental age of at least 9 months

the criteria are not met for autism spectrum disorder

Question 15

what is the DSM5 criteria for disinhibited social engagement disorder?

Answer 15

1. a pattern of behavior in which a child actively approaches and interact with unfamiliar adults
2. the behaviors in #1 are not limited to impulsivity but include socially disinhibited behavior
3. the child has experienced a pattern of extremes of insufficient care
4. the insufficient care causes the emotional and behavioral disturbances
5. the child has a developmental age of at least 9 months

Question 16

what is the clinical presentation of a child with disinhibited social engagement disorder that has a pattern of behavior in which a child actively approaches and interact with unfamiliar adults?

Answer 16

1. reduced or absent reticence in approaching and interacting with unfamiliar adults
2. overly familiar verbal or physical behavior that is not consistent with culturally sanctioned and with age appropriate social boundaries
3. diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings; no social referencing!
4. willingness to go off with an unfamiliar adult with minimal or no hesitation; no stranger danger!

Question 17

what are examples of a child with disinhibited social engagement disorder that demonstrate the child has experienced a pattern of extremes of insufficient care?

Answer 17

1. social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults
2. repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care)
3. rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios)

Question 18

in which populations is disinhibited social engagement disorder more common?

Answer 18

prevalence is low for both and most likely in children adopted internationally from orphanages after the age of 2

may be harder to diagnosis due to absence of neglect when they present for services or lack of background information

Question 19

how do you treat disinhibited social engagement disorder?

Answer 19

1. securing a safe/nurturing environment
2. parent training
3. improving parent – child bond/attachment
4. individual therapy/CBT
5. medication management to address comorbid conditions like anger, irritability, etc.

Question 20

when should you refer a child for suspected childhood disorder?

Answer 20

refer earlier rather than later – children do not always outgrow problems and frequently problems get worse over time

refer when parent reports psychosocial concerns or any significant change from previous functioning

follow up on referral

Question 21

T/F: school refusal may constitute a psychiatric emergency

Answer 21

true

if we don’t jump on this immediately it’s only going to get worse! we need to act quickly to get kids back in school because the longer they’re gone the harder it is to go back

once a kid is home schooled it’s almost impossible to get them back

parents need to make sure that by pulling their kids form school they aren’t reinforcing the idea that the real world isn’t safe

Question 22

what’s the difference between reactive attachment disorder and disinhibited social engagement disorder?

Answer 22

they’re both trauma and stressor disorders that are both child specific

both caused by emotional neglect but they manifest differently!

Question 23

according to erikson, which stage of development is effected in reactive attachment disorder?

Answer 23

trust vs. mistrust

he would say this disorder is caused by mistrust because these kid’s needs weren’t met, their emotional needs weren’t met which effected their behavior – the wiring of their brain is impacted because they were taught from a young age that their needs will never due to the insufficient care

these kids would have a disorganized attachment because they never formed it in the first place

Question 24

what happens is reactive attachment disorder is not treated?

Answer 24

kids do not outgrow reactive attachment disorder!

they have a very high chance of developing personality disorders as adults

their brains are stuck in the developmental stage of a toddler which is why they have extreme tantrums and emotional problems since this is when the trauma occurred so their brains are kind of frozen in that stage

Question 25

T/F: holding therapy is an evidence based treatment for reactive attachment disorder

Answer 25

false

it’s banned as a therapy but in the past therapists would have parents force-hold the kids until they stopped resisting to help facilitate a bond but this doesn’t work and we don’t do it anymore

these kids are really hard to treat though

Question 26

what’s the difference between reactive attachment disorder and autism?

Answer 26

with autism, the kid was well cared for, treated well, formed bonds with their parents etc. but they still have social and communication struggles

RAD has insufficient care with emotional abuse and neglect – they also don’t have restrictive repetitive behaviors

it’s difficult to differentiate if you don’t have an early history though