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Brief, Intensive Treatment for Separation Anxiety in an 8-Year-Old Boy: A Case Study

Tyler C. McFayden1 and Susan W. White2

Abstract Cognitive behavioral therapy (CBT) is the evidence-based treatment modality for children with anxiety disorders; yet, many youth do not receive treatment. To overcome barriers associated with standardized CBT approaches, brief, intensive treatments have been proposed. This case study illustrates a brief, intensive CBT intervention for a preadolescent male client who presented with severe separation anxiety. The intervention consisted of five sessions (one each day for five consecutive days) and a follow-up assessment 4 months later to evaluate treatment outcomes. The intervention strategies were based in CBTs and included exposures, cognitive reappraisal work with both the client and the parents, and reduction of parental accommodation. Reliable Change Indices were calculated to evaluate change from preintervention to the follow- up assessment. There were large and statistically significant decreases in the main outcome measure of separation anxiety symptoms, indicating significant improvements in separation symptoms over treatment per the client’s and parents’ reports. At the follow-up session, the client no longer met diagnostic criteria for separation anxiety disorder. The results highlight the utility of brief, intensive interventions for separation anxiety in young children.

Keywords separation anxiety, brief intensive treatment, cognitive behavioral therapy, exposure

1 Theoretical and Research Basis for Treatment

Separation anxiety disorder (SepD) is characterized by excessive fear or worry concerning separa- tion from caregivers, attachment figures, or from home (American Psychiatric Association [APA], 2013). Prevalence rates estimate that approximately 4% of children in the United States receive a diagnosis of SepD, with the rates being higher in females than in males (APA, 2013). Recent esti- mates suggest that SepD is the most prevalent mental health disorder among children who are 12 years old and younger (Cartwright-Hatton et al., 2006). Given it is one of the most prevalent psy- chological disorders in young children, with some of the earliest ages of onset, it is not surprising

1Virginia Polytechnic Institute and State University, Blacksburg, VA, USA 2The University of Alabama, Tuscaloosa, AL, USA

Corresponding Author: Tyler C. McFayden, Department of Psychology, Virginia Polytechnic Institute and State University, 460 Turner St. NW, Suite 207, Blacksburg, VA 24060, USA. Email: [email protected]

888282CCSXXX10.1177/1534650119888282Clinical Case StudiesMcFayden and White research-article2019

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that being diagnosed with SepD in childhood is associated with a greater risk of developing addi- tional psychopathology later in life (Lewinsohn et al., 2008). SepD is characterized by marked interference in multiple domains of life, including home (e.g., distress at being separated from family at home; difficulty sleeping alone, reassurance seeking), school (e.g., being separated from loved ones during the school day), and with peers (e.g., social limitations as a result of not wanting to be away from family members, decreased social opportunities; APA, 2013). Provided SepD’s early onset, risk factor status, high prevalence rate, and cross-domain interference, it is not surpris- ing that many different treatment approaches have been developed to treat SepD.

Recent evidence from more than 111 treatment outcome studies and 204 treatment conditions demonstrated substantial support for cognitive behavioral therapy (CBT) as the front-line, evi- dence-based treatment for anxiety disorders in children and adolescents (Higa-McMillan et al., 2016). CBT has been studied frequently in the treatment of SepD and has taken on many variants, including a standard, manualized 12-week individual program (Kendall, 1994; Kendall et al., 1997), 12-week group programs (Manassis et al., 2002), modular CBT approaches (Chorpita et al., 2004), 16-week individual and family CBT (Kendall et al., 2008; Kolomeyer & Renk, 2016), and 20-week parent–child CBT with younger children (ages 4–7 years; Hirshfeld-Becker et al., 2010). Standard CBT approaches consisting of a 12-week manualized program (with parental involvement in the case of children) have demonstrated effect sizes ranging from 0.98 to 1.41, indicating robust treatment effects of CBT for SepD (Schneider et al., 2011).

Although CBTs have been established as an evidence-based treatment approach for anxiety disorders, the treatments nevertheless remain underutilized for many children and families (Gunter & Whittal, 2010). Excluding practitioner and clinician barriers, client barriers exist that prevent obtaining or completing treatment. Several barriers to treatment include finances (insur- ance coverage, per-session fees), availability of resources close to home, time, and other family resources (e.g., transportation to therapy). Especially, as younger children tend to require more frequent sessions (e.g., Hirshfeld-Becker et al., 2010), CBT treatments for families of young children with SepD can often last 20 sessions or longer. Importantly, clients and their families may be unable or unwilling to undergo such a lengthy treatment course. SepD is often markedly interfering across life domains, including home, sleep, school, and peers. Understandably, speedy remission is a primary goal for most families. Standard treatment durations of weeks to months, a possible lack of improvement or plateau over the course of the first 4 to 6 weeks, and invest- ment of significant financial and time resources contributes to high attrition and discontinuation in standard CBT protocols.

Due to the numerous costs associated with long-duration psychoeducational or behavioral treatments, brief intensive therapies (BITs) have gained traction to reduce the amount of time and resources required to complete treatment. BITs involve shorter durations of treatment with larger chunks of face-to-face interventions instead of the classic 60-min per week approach. BITs have demonstrated efficacy in treating many anxiety disorders including panic disorder and agorapho- bia (Pincus et al., 2010), obsessive-compulsive disorder (Storch et al., 2010), eating refusal (Williams et al., 2011), and specific phobias (Muskett et al., 2020; Ollendick et al., 2009). To date, only one BIT has been conducted and evaluated for children specifically with SepD (Santucci & Ehrenreich-May, 2013). The Child Anxiety Multiday Program (CAMP) consisted of a BIT that lasted 7 days in an overnight camp structure. CBT was specifically targeted to address SepD in female children aged 7 to 12 years. The CAMP program used a combination of child- only and parent-only sessions, including exposure sessions, cognitive reappraisal techniques, muscle relaxation, and somatic training. CAMP resulted in significant reductions in SepD sever- ity, functional impairment, and parent report of the child’s SepD symptoms. While the CAMP program has not yet been compared with treatment as usual or 12-week manualized CBT treat- ments for SepD, the BIT format continues to hold great promise for treatment of SepD in children and adolescents.

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The CAMP program demonstrated significant reductions in females’ SepD symptoms over the course of 7 days, and gains were sustained at a year-long follow-up. However, there were certain limitations of the CAMP program: the participants receiving treatment were all female, the families had consented to an overnight camp and/or traveled to receive treatment, and treat- ment lasted a full week, including one weekend. Thus, the CAMP treatment is not yet generaliz- able to other demographics, or applicable to families who may not be able to provide weekends, overnight stays, or travel to receive treatment. The current case study presents a BIT with an Indian male, aged 8 years, which did not require overnight participation and lasted only 5 days with parent and child participation. The structure of treatment sessions was adopted from the CAMP protocol (Santucci & Ehrenreich-May, 2013) to address severe SepD and family accom- modations in a family of a young male, where overnight or 12- to 16-week treatment as usual were not viable options.

2 Case Introduction

Identifying information has been modified to ensure the client’s anonymity. The client, Raj Patel, was an 8-year-old boy of Indian descent who lived with his biological parents, Mr. and Mrs. Patel. English was the primary language spoken in the home. Mr. Patel sought an assessment and subsequent treatment at the clinic where the author was a therapist providing CBT treatment. Raj’s parents sought an assessment and treatment to clarify current school concerns regarding anxiety, specifically separation anxiety. Raj presented with previous diagnoses of SepD, social anxiety disorder (SAD), and autism spectrum disorder (ASD). Raj reportedly experienced sepa- ration anxiety since he was 3 years of age. Mr. and Mrs. Patel wished to work with our center, given expertise in ASD and anxiety, and so traveled across several state lines to receive the assessment and treatment process. Permission for the publication of this case study was obtained from Mr. and Mrs. Patel.

3 Presenting Complaints

Raj presented at the clinic with primary referral concerns of separation anxiety. Mr. and Mrs. Patel reported that Raj demonstrated symptoms of separation anxiety since he was a young child, and that he spent most of his time outside of school with his parents at home or at their places of work. Mr. and Mrs. Patel reported that Raj had significant difficulty with SepD at home, includ- ing difficulty sleeping alone and being alone in a room in the house without his father. Mr. Patel reported that he had previously slept with Raj in the same bed of a bunk bed, but more recently he slept in the other bunk as Raj every night. Mrs. Patel reportedly slept in the parent’s bedroom. Raj reported that he preferred to have his dad sleep next to him at night due to worries about hav- ing bad dreams about being separated from his father. Mr. and Mrs. Patel reported that they had not taken a date night since Raj was born due to their anxiety about leaving him and Raj’s anxiety about being away from his parents.

Socially, symptoms of SepD were mildly interfering. Mr. and Mrs. Patel reported that Raj was not allowed to participate in sleepovers due to a combination of parent-reported and child- reported anxieties regarding separation. Per parent and teacher reports, Raj’s anxieties about being away from his father often resulted in whining behaviors or withdrawal when with peers.

Mr. and Mrs. Patel had previously not sought treatment for SepD due to its lack of significant interference socially or academically. However, they reported that at the time of assessment, Raj’s anxieties about separating were causing substantial interference at school, in particular, as Raj was perceived to be disruptive to the class when experiencing anxiety. Raj reported that he worried excessively about being picked up on time by his parents, although parents were report- edly reliably punctual. As a result, Mr. and Mrs. Patel reported that Raj would often fidget in

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class, whine, or become hyperactive when thinking about his father being late. Raj’s teachers also reported that he often distracted other students and/or became too preoccupied by his own worry to complete work. Raj’s worry in the classroom was so pervasive that for the first week of school, Mr. Patel spent the day outside of the classroom so Raj could see him if needed.

4 History

Raj was born in the United States with his parents speaking English in the home. Raj received a diagnosis of ASD at the age of 4 years from his primary care physician. His parents recalled the diagnosis was a result of his language delay. Raj reportedly had no speech until 3 years of age. Raj received applied behavioral analysis and early interventions for his ASD diagnosis from 2014 to 2016. In addition, Raj received speech therapy for delayed speech from the ages of 3.5 to the start of Kindergarten (age 5). He also received occupational therapy services and behav- ioral treatment for language related to ASD. Raj previously received online CBT therapy for his anxiety through a modular approach (without guidance from a therapist), which included graph- ics connecting thoughts to behaviors to emotions, and online worksheets and games to draw upon those connections. Raj also previously participated in online game-based approaches to help with executive functioning and online virtual reality therapies for theory of mind development.

At the time of assessment, Raj had completed the second grade. Raj reportedly received A’s and B’s in his classes. Per parent report, Raj’s behavioral and social difficulties were most pronounced in the school setting. Specifically, Raj’s parents noted that they received calls from his teachers due to concerns related to refusal to complete assignments, chewing on his pencil, and social anxi- ety (e.g., won’t engage within groups, won’t leave seat, will not speak to others, whines in class). Raj reportedly had limited social relationships with other children in the school setting and at home and was not involved in any extracurricular activities (e.g., clubs, sports) at the time of treat- ment. Mr. Patel reported that Raj had experienced anxiety for most of his life. Starting around 18 months of age, Raj would not leave his father’s lap to engage in therapies. When Raj was 5.5 years of age, his separation anxiety increased to the point where Mr. Patel spent every day for 1 week immediately outside Raj’s classroom door so Raj could see his father when they left the classroom. Raj’s anxiety was reportedly interfering more in home life, social life, and in school settings, which prompted his parents to seek targeted treatment. Mr. and Mrs. Patel sought services primar- ily due to teacher-reported difficulties sustaining attention in class, disrupting other students, audi- bly whining in class when nervous, and reassurance seeking toward the end of the day regarding the school pick-up times. These disruptive behaviors were conceptualized by the clinicians and parents as stemming from SepD, but were conceptualized by the school system as stemming from ASD. Raj had a 504 plan at the time of assessment, which included supports to address some of the interfering behaviors, such as a weighted blanket for his lap for hyperactivity, a chewy for oral fixations, and small breaks throughout the day. Mr. and Mrs. Patel worked closely with Raj’s teachers to provide them with common language to use when Raj was upset and to help him calm down. Mr. and Mrs. Patel had also set up an app where the teacher could report on Raj’s SepD classroom behaviors each day. Raj’s school system reportedly grew intolerant of Raj’s behaviors in the classroom and had been suggesting placement in another school system. Although Mr. and Mrs. Patel reported that Raj’s anxiety around separation was not as bad as it once had been, the reported severity levels in a multitude of settings continued to be interfering.

Raj’s parents both received advanced degrees and were employed in medical and/or academic positions. Mr. and Mrs. Patel endorsed elevated levels of anxiety themselves, including anxieties around parenting, specifically. Mr. and Mrs. Patel did not endorse any marital difficulties, family history of psychopathology, or high levels of stress. The family self-identified as Indian and cul- tural beliefs were discussed briefly in the frame of cultural implications for treatment; however, no apparent cultural implications were present.

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5 Assessment

Raj participated in a comprehensive assessment 6 months prior to the first treatment session. Mr. and Mrs. Patel did not initially seek treatment. This comprehensive evaluation reassessed Raj for his diagnosed ASD, in addition to other presenting concerns including anxieties. Based on the evaluation and case conceptualization, Mr. and Mrs. Patel returned to the clinic 6 months later for treatment.

Autism

The Autism Diagnostic Observation Scale (ADOS-2; Lord et al., 2012) is a 45 to 60-min obser- vational assessment for children and adolescents with fluent speech. All ADOS-2 modules show excellent sensitivity and specificity, with all subdomain scores equating or exceeding 0.85 as indicated by receiver operating characteristic curve (ROC) analyses (Gotham et al., 2007). Raj’s ADOS-2 classification fell within the nonspectrum range. The comparison score suggested that there was low evidence of behavior characteristic of ASD. The Autism Diagnostic Interview– Revised (ADI-R; Lord et al., 1994) is a semi-structured interview for caregivers of children and adults with ASD. The ADI-R demonstrates good-to-excellent reliability and validity (Lord et al., 1994) and is considered a gold-standard assessment measure for ASD. Based on this structured interview, Raj demonstrated some characteristics of ASD beginning in early development related to communication, but not reciprocal social interactions or restricted, repetitive, stereotyped behavior. Therefore, based on clinical judgment and data from the ADOS-2 and ADI-R, he did not meet the established cutoff scores for an ASD diagnosis.

Anxiety

The Anxiety and Related Disorders Interview Schedule-V-Parent Version (ADIS-P-V, Brown & Barlow, 2014) is a semi-structured interview administered to parents that assesses a wide range of psychiatric disorders in childhood. The ADIS-P has demonstrated acceptable to excellent test– retest reliability estimates (k = .61–1.0) for diagnoses based on parent, child, and combined reports for children and adolescents aged 7–16 years (Silverman et al., 2001). Interrater reliabil- ity estimates have been reported as excellent for all anxiety disorders (k = .80–1.0; Lyneham et al., 2007).

Both parents reported overall elevations on the SAD module and the SepD module. During the social anxiety module, Mr. and Mrs. Patel endorsed elevations in situations including starting and maintaining conversations with strangers or new/unfamiliar people, being called on by the teacher, reading aloud in front of the class, and playing with a group of kids. They reported that Raj’s coping behaviors in these situations were to avoid or stop speaking and to cling to his par- ents or hide behind them. Mr. and Mrs. Patel endorsed clinically elevated symptoms of SAD and remarked that it was significantly impairing in his school performance and in his social life.

During the SepD module, Raj’s parents reported that he worried excessively if he is not with his parents and will do whatever he can to be with him, particularly his father. They endorsed seven symptoms of SepD, including getting upset and worrying ahead of time if his parents plan to leave or go somewhere without him, worrying that he will not getting picked up from school, being away from his parents in school, complaining of somatic sensations when going to school, wanting his parents to stay close to him at night, and worrying that something bad might happen to himself and his parents when they are separated. Mr. and Mrs. Patel reported that Raj slept with his father at night and had significant anxiety to be in a room alone in the house. Mr. and Mrs. Patel reported significant distress and interference as a result of Raj’s SepD symptoms.

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The Screen for Child Anxiety and Related Emotional Disorders–parent and child versions (SCARED-P/C) is a measure of anxiety symptoms that group into five symptom clusters includ- ing panic/somatic symptoms, generalized anxiety symptoms, separation anxiety symptoms, social anxiety symptoms, and significant school avoidance. The SCARED boasts good internal consistency, test–retest reliability, discriminative validity between and within anxiety disorders, and moderate parent–child agreement (Birmaher et al., 1997).

The SCARED, in particular the SepD subscale, was used as the primary outcome measure for treatment improvement. Mr. and Mrs. Patel were administered the SCARED at four time points, including at the initial assessment, at the start of treatment, at the end of treatment, and at follow- up approximately 4 months later. Raj completed the SCARED at three time points, including pretreatment, posttreatment, and follow-up. At assessment, both Mr. and Mrs. Patel reported clinically elevated symptoms of SepD (scores = 10 and 9, respectively; clinical cutoff = 5, maximum score = 16). These results indicated that both caregivers viewed Raj as demonstrating clinically elevated symptoms of separation anxiety, social anxiety, and total anxiety.

Accommodations

The Family Accommodation Scale for Anxiety (FASA) is a self-report measure of the family accommodations provided to the child due to anxious symptoms (Lebowitz, Wollston, et al., 2013). The FASA demonstrated acceptable convergent and divergent validity with the SCARED (Lebowitz, Omer, et al., 2013). Raj’s father scored 14 and his mother scored 9. In a clinical sample of individuals with an overall SCARED score of 30, the mean accommodation score was 13.24 with a standard deviation of 8.84 (Lebowitz, Wollston, et al., 2013). Results indicated that Raj’s parents reported inconsistent levels of accommodation, with Mr. Patel providing more accommo- dations and Mrs. Patel providing lower levels of accommodations for Raj’s separation anxiety.

6 Case Conceptualization

Raj is a young boy who presented with SepD, social anxiety, and some broader autism pheno- type presentations but without a clear ASD diagnosis. Raj demonstrated some behaviors con- sistent with ASD, including delayed language history, sensation-seeking behaviors (e.g., oral sensory seeking, chewing), formal language, limited social insight, and difficulties with peer relationships. However, Raj also demonstrated many strengths, including appropriate eye con- tact, good gesture use, reciprocal conversation, variable facial expressions, social smiling, interest in others and direct questions about and to others, and a lack of restricted or repetitive behaviors. Due to Raj’s subclinical scores on gold-standard measures assessing for ASD (e.g., ADOS-2 and ADI-R), paired with clinical judgment, Raj’s ASD diagnosis was not supported, and his symptoms were conceptualized as relating to his SepD diagnosis. In particular, many of his sensory symptoms (e.g., chewing) were present only when he was worried about his dad picking him up from school. Much of his social withdrawal or hesitation to engage with peers, as reported by teachers, was directly related to his social worries (e.g., fear of negative evalu- ation), and worries regarding being away from his parents when engaging with peers at a playground or at a friend’s house. Thus, many symptoms that could have been described as relating to ASD, potential inattention, oppositionality/defiance, or social withdrawal were, indeed, related to SepD psychopathology.

Regarding Raj’s anxious symptoms, his SepD was reported as most interfering in home and school contexts. Raj verbalized anxiety when separated from his parents and experienced addi- tional anxiety when away from his parents that he did not verbalize until after the matter (e.g., after the first session, he reported, “I was nervous during the first hour”), likely due to not want- ing to come across as anxious, or being too nervous to express his anxiety in the moment without

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his parents present. Raj was able to link his feelings to his thoughts appropriately and was able to apply the concepts easily. Raj demonstrated some separation and social anxiety, including limited social motivation to engage with others unless prompted to do so and provided with reinforce- ment after doing so, clinging behaviors to his parents, in particular his father, and checking in with them about where they were going to be and if they were going to leave during session.

Raj’s parents demonstrated accommodating behaviors and anxiety regarding their separation from their son. Mr. and Mrs. Patel reported that they had never left Raj alone since he was born, as a result of their own anxiety. They also reported that they have not gone on a date since he was born, indicating their anxieties surrounding leaving their son, and their accommodating nature regarding changing their entire schedule to accommodate their son. This anxiety extended to reasons why Raj is not in social extracurricular activities (they are afraid of getting a negative phone call), and why he is not allowed to spend the night at other children’s homes, even though he has been invited and wants to go. These behaviors did not appear to be culturally driven or reflective of a co-sleeping consistent with cultural values or religious beliefs of the family. The parents’ accommodating behaviors reduced Raj’s autonomy and thus increased his worries about how things will go when he is expected to do things independently, such as go to bed. Raj is also a sensory seeker and thus enjoys the physical closeness that his family provides, including during bedtime and in the morning, and often requests hugs or cuddles that allow for smelling and touch- ing sensations. Raj’s parents may overinterpret his need for sensory input as a desire for physical closeness at all times, thus overextending his separation anxieties into contexts where he other- wise is not anxious.

Raj’s anxieties in separation-possible situations, or situations in which a separation has already happened, are best conceptualized as an interactive and recursive model between his own anx- ious tendencies and cognitions (e.g., “they will forget me,” “they will never come back for me”), behaviors (e.g., verbal fretting helps him calm down, whining provides background noise that is soothing), and feelings (e.g., anxiety, panic, somatic symptoms) and his parents’ anxieties and accommodating behaviors (e.g., refusing to go on a date night, anxieties around leaving their son). The parents’ and child’s behaviors, in turn, reinforce each other during stress situations. For instance, Raj expressed extreme anxiety surrounding not being picked up for school, so his par- ents continued to get to the carpool line early or park and walk in to pick him up. Then, when Raj did not see his father there early, or there in person, his anxieties spiked, which exacerbated the patterns of behaviors. As a result of the recursive, interactive model between Raj’s anxieties and his parents’ anxieties and low tolerance for distress, treatment should focus on addressing cogni- tions, behaviors, and emotions present in Raj, and in his parents. Family CBT approaches to CBT are best suited for Raj and his family given the presentation of interfering symptoms in home, school, and social settings. Raj is intellectually advanced enough to benefit from labeling cogni- tions, feelings, and connecting these to his behaviors. Given the interactive effects of parental anxieties and accommodations, family involvement in CBT is crucial to address the system of SepD accommodation.

Importantly, Raj’s current symptoms are reportedly markedly interfering at school, at home, and socially with peers. As the school is reportedly growing intolerant of Raj’s behaviors, which are conceptualized here as relating to SepD, Raj and his family will benefit from a brief, intensive treatment modality in which treatment gains can be seen quickly to more immediately improve school outcomes and SepD behaviors.

7 Course of Treatment and Assessment of Progress

The Patel family received treatment for a total of 5 days, averaging 4 hr of treatment per day. Treatment durations ranged from 1 hr (final day) to 6 hr (Day 3). A treatment team comprised four clinicians, all of whom were doctoral students in clinical psychology under the supervision

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of a licensed clinical psychologist (second author). The primary clinician (Clinician 1; first author) was present for all sessions. The outlined sessions for each hour of treatment are available in Table 1.

Table 1. Outline of Session Structure for Assessment and Treatment.

Time Participants Topics to be covered/Measures administered

Assessment: 6 months pretreatment (3 hr) Hours 1–3 Parents, Clinician 1 Measures: Informed consent, ADIS-P-V, SCARED-P Session 1: Intake and Introduction (3 hr) Hour 1 Parents, Clinician 1 Measures: Informed consent, ADIS-P-V, SCARED-P/C, FASA Hour 1 Child, Clinician 1 Arts and crafts activity to warm up, discuss feelings, facial

expressions Hours 2–3 Parents, child,

Clinician 1 CBT psychoeducation, exposure rationale, SUDS, rewards,

create fear hierarchy Session 2: Cognitions, exposure hierarchy, small exposures (4 hr) Hour 1 Parents, child,

Clinician 1 Cognitive restructuring activities: Introduction to ANTS,

cognitive distortions, finalize fear hierarchy. Practice first exposure.

Hours 2–4 Parents, Clinician 3 Problem-solving, autonomy granting, differential reinforcement skills, tolerating distress

Hours 2–4 Child, Clinicians 1, 2

Pottery painting and lunch away. Address two exposure hierarchy items.

Session 3: Somatic experiences, exposures (6 hr) Hours 1–2 Parents, child,

Clinician 1 Continuing cognitive restructuring, interoceptive exposures,

somatic symptoms and habituation to somatic experiences, prepare for evening work. Flex time.

Hours 3–4 Parents, child, Clinicians 1, 3

Visit playground for social interactions. Parents work with Clinician 1 on decreasing parental accommodations in social contexts

Hours 5–6 (Bedtime)

Child, Clinicians 1, 3

First bedtime alone practice. Parents out to dinner or on “date night”—must leave premises. Familiar clinician implements bedtime routine.

Session 4: Progressive muscle relaxation, highest exposures (6 hr) Hours 1–2 Parents, child,

Clinician 1 PMR, when to use PMR, SUDS, activity using PMR, review

CBT skills, ANTs, and treatment planning. Hours 3–4 Parents, child,

Clinician 1 School/classroom separation exposure with classroom noise

and work Hours 5–6

(Bedtime) Child, Clinicians

1, 4 Second bedtime alone practice. Unfamiliar clinician as

“babysitter” to address bedtime anxieties hierarchy Session 5: Discharge and treatment planning (2 hr) Hour 1 Parents, child,

Clinician 1 Goal setting, relapse prevention (lapse vs. relapse), awards

Hour 2 Parents, Clinician 1 Discharge measures, discuss parent goals Hour 2 Child, Clinician 3 Small activity or game, reward, and certificate Session 6: 4-month follow-up (1 hr) Hour 1 Parents, child,

Clinician 1 Measures: SCARED-P/C, ADIS-P-V Separation Anxiety

module

Note. Clinician 1 = first author. ADIS-P-V = Anxiety and Related Disorders Interview Schedule-V-Parent Version; SCARED = Screen for Child Anxiety and Related Emotional Disorders (Parent/Child); FASA = Family Accommodation Scale-Anxiety; CBT = cognitive behavioral therapy; SUDS = subjective units of distress; ANTs = automatic negative thoughts; PMR = progressive muscle relaxation.

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Session 1

Session 1 comprised completing intake measures, informed consent, rapport building, and brief introductions to CBT and psychoeducation. During the first session, both parents demonstrated some apprehension toward discussing details, especially regarding their parenting strategies and difficulties at home; they reported zero difficulties at home with any behaviors. Raj was first familiarized with his reward paradigm which included receiving stickers on a schedule to allow him to pick out a certificate each day. For larger events, Raj was able to pick out a “squishy”—a small rubber animal—if he completed tasks well. Raj appeared excited and motivated by his structured reinforcement paradigm. Rapport building was conducted via brief games with par- ents, clinicians, and Raj. Raj appeared easy to engage and excited to work with the clinicians. Worksheets to introduce CBT were selected from the Coping Cat CBT program (Kendall, 1994). Raj demonstrated appropriate understanding of the concepts of exposure, thoughts–feelings– behaviors, “being brave” in situations, and labeling “butterflies,” or subjective units of distress (SUDS). The client was also able to report how his thoughts, feelings, and behaviors were inter- connected. The client, along with his parents and the clinician, created a fear exposure hierarchy. Raj reported that several specific situations were at a “100,” including waiting for his dad to pick him up from school and being late, going on an outing with the clinician and someone he doesn’t know, riding on an elevator alone, and so on. As a result of one of the items (e.g., going down- stairs to fetch something for the clinician by himself) was rated a 30, that was the first exposure conducted during session. The clinician explained why it is important to “stay in the situation” and not avoid, which he understood and recited back. The client successfully went downstairs by himself and got a piece of paper for the clinician. He rated his initial fear as a 10, and when he returned, a 9.

Session 2

Session 2 comprised two sections: an in-office didactic session for the family paired with an out- of-office activity and exposure for the child and a simultaneous in-office didactic for the parents. Out-of-office exposures were always conducted with two clinicians to address issues of child safety, even if only one was directly working with the client at that time. In the didactic portion of Session 2 with the whole family, the client and clinician discussed automatic negative thoughts (ANTs). The client decorated his own ANTs (pictures of ant insects with quote bubbles indicating specific negative thoughts) and worked on identifying “antidotes” to poisonous thoughts via a worksheet. The client reported it was “boring” and required several short breaks. The client was able to generate “replacement thoughts” to ANTs. Next, the client and two clinicians traveled to the mall for an exposure, including being with caretakers he does not know very well (the second clinician), being away from parents in an unfamiliar place, and parents being late to pick him up from an outing. Raj was not aware that he was going to complete his largest exposure item during this time with the rationale to disambiguate anticipatory separation anxiety from that felt during an instance of separation. During the outing, the two clinicians and client ate lunch and painted pottery. The client reported his SUDS as low or nonexistent for the duration of the trip. The clini- cians brought the client back to the clinic and reported to him that his parents would arrive at 1:15 p.m. However, the parents were instructed not to arrive until 1:45 p.m., both to improve their tolerance of distress and to serve as an exposure for the client. During this time, the clinician informed the client that his parents were running late to pick him up. He reported low SUDS (score = 1), but demonstrated some anxious behaviors including insisting on looking out the window to wait for his parents and asking for the time every 2 min (the answer was not provided to him, as this was deemed a safety behavior). The client reported that his thoughts were that his dad was “eaten by a monster” and had died. When asked whether the thought was helpful, he

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reported “no.” He was able to generate other thoughts, namely that “they are stuck in traffic but on their way.” Upon the parents’ arrival, the client was able to dictate to his parents that he used “replacement thoughts” to feel better, and his “replacement thought” was the one that came true.

While the client and two clinicians were in the out-of-office exposures, a third clinician worked with both parents on family accommodations, tolerating distress, and differential rein- forcement for 90 to 120 min. Specifically, the clinician worked in the modules of the SPACE parent training program for parents with children with SepD to identify the accommodations the family is engaging in and developing a plan as a group to reduce accommodations (Lebowitz, Omer, et al., 2013). The clinician also worked with the parents on how to communicate a reduc- tion in accommodations to their child, including reinforcement and rewards systems (e.g., limit- ing calling once per day with iPad time as a reward). As the session continued, the parents opened up more about their parenting difficulties and struggles at home. In particular, Mr. and Mrs. Patel revealed that their parenting strategies and perspectives differ greatly, resulting in differences in opinions about how matters should be handled related to anxiety, differences in consistencies in which reinforcements or punishments are handled, and often disagreements verbally that result in “one undermining another.” As the sessions continued, both parents came to terms with their roles in the treatment and sought to better understand how their anxieties contributed to Raj’s presentation. Both parents, toward the end of treatment, sought to increase Raj’s autonomy and decrease their accommodating behaviors.

Session 3

Session 3 comprised three distinct sections, including an in-office didactic with all parties, an out-of-office exposure and parent training session, and a third out-of-office exposure at bedtime. First, the clinician met with the parents and client to review and conduct interoceptive exposures. The clinician reviewed the importance of linking feelings to thoughts to actions in the body. The client reported that when nervous, he feels like throwing up, feels like his muscles are tight, and feels his heart beating quickly. As a result, the exposures focused on inducing and tolerating those bodily sensations. After each exposure, the client was encouraged to close his eyes and experi- ence the feeling and then answer three questions, including “how did it feel,” “what were your thoughts,” and “how anxious were you from 0 to 10?” The client and clinician did several activi- ties, including high knees (shortness of breath), heel raises (leg tightness), and squeezing imagi- native lemons (hand and arm tightness). The client did not report any thoughts or anxiety throughout the exposures. Finally, the client and clinician alone reviewed CBT and talked about a “hero” or TV character that experiences anxiety. The client chose “Catboy” from “PJ Masks” and reported that when nervous, he “runs away.” The clinician and client then reviewed a short clip of Catboy when nervous to see what he actually does. The client then reported that Catboy “talks to his friends,” “asks them for help,” and “labels his feelings.”

For the second part of the session, two clinicians met with the client and the client’s parents at a local park frequented by other children during the afternoons. The primary clinician met with the parents in a structure approximately 100 yards from the child and out of the child’s sight. The cli- ent did well with the separation and did not request that his parents stay close to him at the park. While with the parents, the clinician discussed the typical bedtime routine, what the perceived difficulties are for the child and parents, and how his week is structured, socially. The parents reported that his typical bedtime routine involves watching a show, reading, listening to music, and going to sleep with his father in the other bed, without much difficulty. Regarding separation at night, the parents reported that the client has never been left alone before, and the parents have “never been on a date” in the past 8 years. The clinician echoed the importance of autonomy grant- ing, including not calling the clinician and enjoying the night out during the upcoming session. The clinician also discussed the importance of social, unstructured interactions for the client, such

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as a rec. soccer league, visiting local parks, sleepovers, or play dates. The client’s parents reported that they agreed they need to allow more opportunity for social interaction. After an hour, the clini- cians, clients, and parents rejoined and focused on the client joining and initiating with peers. A clinical supervisor and her children were at the park to introduce an age-appropriate play mate with whom to practice initiating and joining in group play. The client was anxious at first and reported he would rather play on the train. The clinician encouraged him with a reinforcement item the child requested during the previous session. The client still refused to engage. The client’s mother also reinforced his behavior and suggested he attempt. Upon his mother’s prompting, he approached the children and introduced himself by extending his hand for a handshake and asking the other children’s names. Then, he joined in a game of ball tag and played with the group for approximately 30 min before departing.

For the third part of the session, two clinicians arrived at the client’s hotel room for the eve- ning session to practice sleeping with separation from the parents. The parents had the client prepare for bed, including showering, eating, and getting on his pajamas. The clinicians arrived at the hotel room and the parents said their goodbyes and reported they were going “to a concert” and would be back after the child was asleep. The parents reported to the clinicians, in private, that they would get something to eat and then “buy time” until he was asleep. They reported, “don’t be alarmed if you see us in the lobby,” thus demonstrating some anxiety about straying too far during the separation related to sleep. At 8:30, the client willingly started the getting ready for bed process, including dimming the lights, brushing his teeth, and choosing a bedtime story to read. The client asked about his parents, and the clinician reported that they would be back after he was asleep. The client did not ask any other questions of the clinician or request any additional accommodations. For the next half hour, the clinicians remained in the hotel room to see whether the client would call out, leave the room, or if the parents would call in to check. The client did not demonstrate any separation anxiety-related behaviors and remained asleep in the bed. The parents, also, remained at their event until the clinicians gave them the “go-ahead” to return. The clinicians discussed the bedtime routine and how it went with the parents, who demonstrated some guilt and shame about their previous bedtime issues. They reported, “maybe he just needed new parents.” The clinicians provided brief reassurance and suggestions for work tomorrow, including debriefing further.

Session 4

Akin to the third session, the fourth session included three sections: (a) an in-office didactic with the family, (b) an in-office exposure to mimic a school classroom, and (c) an out-of-office bed- time routine exposure. First, the clinician met with the family and introduced progressive muscle relaxation (PMR), including conducting PMR sessions, labeling SUDS during PMR, and dis- cussing when PMR is appropriate to use and in what contexts. The client reported that he enjoyed PMR and that he felt more relaxed after doing the PMR. The clinician and family discussed when PMR could be useful, such as in the classroom, when things get too noisy, when someone says something mean about him, or when he wants to relax without leaving the room. The client and clinician also practiced “spidey senses” including focusing on other senses when some are over- whelming, such as focusing on touch or feel to help dampen down the noise. The client reported that he could also try that in the classroom.

Next, the clinician and client worked on a “school” exposure and attempted to recreate a class- room environment, including classroom noise, school-related tasks, a schedule, and shifting from topic to topic at a school-rate to closely replicate any anxiety in school-related contexts. The cli- ent completed math and grammar based on the structure and time allotted in the classroom, with a soundtrack of classroom ambient noise. The client was able to work quietly and independently without any direction. The client often relied on some sensory input to his mouth and chewed the

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pencil, eraser, plastic, and so on. The parents reported that the client often has a chewy during classroom time, or speaking and talking during the classroom time reduces his need for oral sen- sory input.

For the second session of the day, two clinicians arrived at the client’s hotel room to conduct the second nighttime exposure. The primary clinician, whom the client knew well, remained in the lobby for two purposes: to remain out of sight of the client (to reduce safety signals) and to check that the parents went out of the hotel to a date or social function to assess autonomy grant- ing and their own tolerance of distress. The parents left to go to dinner. The novel clinician (unknown to client) conducted bedtime routines with the client. The client and clinicians played hide-and-seek for 30 min. The client then stated that he was ready for bed. He brushed his teeth and listened to one story. When the story was over, he asked the assisting clinician if she could stay in the room until his parents came back. She reminded him he was working on sleeping on his own and reminded him that they were working on being brave. After the novel clinician had put the client to bed, the primary clinician entered the room to monitor for calling out, anxieties, or other post-bedtime behaviors. During this time, the client opened and closed the door repeat- edly, about once every 5 min. The assisting clinician checked on him after the fourth occurrence, and the client reported that he was afraid of the dark. The clinician used the same phrasing to “be brave” and put him back to bed. After that singular occurrence, there were no additional instances of the client leaving bed.

Session 5

Session 5 was the final wrap-up session including discharge assessments and goal setting. The clinician met with the parents and the client to discuss the past night, including any anxiety, thoughts, ANTs, and feelings. The clinician then worked with the group to develop appropriate goals for the next month related to separation, for both the parents and the child. The client identi- fied several of his own goals, including sleeping by himself every night, remaining calm and using relaxation during school time, and trying the school drop off instead of being walked into class. The client also identified his preferred rewards, including working toward sleepovers as a result of sleeping independently, and working toward points to earn a prize in school. The parents also identified four goals, including increasing the client’s autonomy, letting the client sleep independently every night, letting the client feed himself independently, and letting the client attend sleepovers at other children’s homes. Finally, the clinician met with the parents to conduct posttreatment assessments, whereas a second clinician played reward games with the client.

Assessment of Progress: SCARED Scores

The SepD subscale of the SCARED was used as the dependent measure of interest to evaluate treatment progress overtime. All three reporters (mother, father, and child) reported clinically elevated symptoms of separation anxiety at assessment and pretreatment. At the end of treatment 5 days later, Mr. and Mrs. Patel’s and Raj’s scores for separation anxiety symptoms were still above clinical threshold.

8 Complicating Factors

The complicating factors in this case were several, including some diagnostic factors, some logistic and travel considerations, and timing of treatment (e.g., summer months). First, the client had a previous diagnosis of ASD. However, upon the receipt of a comprehensive psychological assessment 6 months prior to treatment, with the administration of gold-standard ASD measures, the diagnosis of ASD was no longer supported. However, the client did demonstrate some ASD

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symptoms, including sensory-seeking behaviors (e.g., needing squeezes, seeking out oral sensa- tion). Thus, while the ASD diagnosis was not applied, the client still demonstrated some behav- iors of ASD during treatment. These behaviors did not interfere with treatment fidelity or the client’s participation in treatment, but is a complicating diagnostic element worth noting, as Raj’s school had reportedly conceptualized the behaviors as stemming from his ASD diagnosis, as opposed to SepD. Importantly, many of the behaviors that Raj demonstrated in the classroom (e.g., chewing, lack of paying attention, whining, lack of social engagement) had been attributed to his ASD diagnosis by the educational professionals. These behaviors were reconceptualized as resulting from SepD by clinicians (and parents following treatment and psychoeducation).

Second, there were travel and logistic features that complicated conducting the exposures. As the family traveled from a significant distance to participate in the brief, intensive treatment, they were not spending the nights in their own home. Thus, the bedtime routines were carried out in a hotel instead of the client’s own bedroom at home. While the family reported that the behaviors and exposures generalized quite well, ideally these exposures would have been able to take place in the client’s own home to address safety behaviors and parental anxiety–related behaviors that would occur in their natural context.

Third, the timing of treatment was a final complicating factor. Mr. and Mrs. Patel’s largest concern was Raj’s performance in school, as his school performance was largely affected by his SepD symptoms. Raj’s highest item on his exposure hierarchy was not being picked up from school or being forgotten by his parents. While the clinicians were able to recreate this exposure in another setting (e.g., not being picked up from an activity or an outing), the exposures were not able to be done in the school setting or during the school day. This may be a complicating factor that limited the generalizability to school settings. However, the uncertainty and newness of these situations may actually have served Raj well in truly elevating his separation anxiety.

9 Access and Barriers to Care

Raj and his parents reside in a resource-rich area with many options for psychological care. Mr. and Mrs. Patel have the means and dedication to seek out treatment services and travel to partici- pate in novel and innovative treatment approaches, such as the one discussed here. However, Mr. and Mrs. Patel reported feeling unsupported in Raj’s school system. Given Raj’s previous diag- noses and difficulties in school related to separation, the school system reportedly suggested that Raj find alternative placement for his education. Thus, Mr. and Mrs. Patel faced adversity in getting the school on board for Raj’s treatment protocols and academic accommodations. Due to the pressure from the school to have Raj’s symptoms managed quickly, Mr. and Mrs. Patel were outstanding candidates for brief, intensive treatment.

10 Follow-Up

The SCARED and the ADIS-P-V were conducted 4-month posttreatment over the phone due to geographic distance factors. Mr. and Mrs. Patel completed the SCARED-P and the ADIS-P-V, whereas Raj completed the SCARED-C. As the SCARED was the primary dependent variable of interest, the SepD subscale was used to identify treatment progress over time. At the 4-month follow-up assessment, all three reporters’ scores were below the clinical threshold on the SepD subscale of the SCARED. For visual inspection of the SCARED SepD subscale, see Figure 1.

To evaluate the reliability and clinical significance of the client’s symptom change, the Reliable Change Indices (RCIs) were computed for all three reporters (mother, father, and child). RCI is calculated by dividing the difference between pre- and follow-up scores on a measure by the standard error of the difference. A score of ±1.96 indicates clinical significance (Jacobson & Truax, 1991). RCI scores for all reporters on the SepD subscale of the SCARED were each

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greater than −1.96, indicating that each reporter rated significant improvement over the course of treatment and follow-up (Table 2).

The secondary dependent measure to evaluate the diagnostic construct of SepD was the ADIS- P-V, completed by Mr. and Mrs. Patel. Per their report on the module, Raj continued to demon- strate two symptoms of separation anxiety, including fear of not being picked up from school, and fear of being alone in certain rooms of the house. Per the parents’ reports at the time of fol- low-up, Raj was sleeping independently each night and had appropriately managed his anxious symptoms during the school day and at night using several coping strategies. Mr. and Mrs. Patel reported that they had gone on a date night and left Raj with a sitter or friends. The clinician severity rating for separation anxiety was a score of 1, indicating that Raj no longer met diagnos- tic criteria for SepD.

11 Treatment Implications of the Case

Findings from this case study indicate that substantial progress can be made using BIT in chil- dren to improve symptoms of SepD. As the current study required five total days, with the last day including a discharge session and debriefing, this is preliminary evidence to suggest that significant symptom reductions can be made in as little as 1 week of treatment. Previous work conducted on BITs for SepD has been in the form of an overnight camp format and only with females (Santucci & Ehrenreich-May, 2013). This current case study extends and replicates the previous work and indicates that similar progress can be made in young males without requiring

Figure 1. SCARED separation subscale by reporter across treatment. Note. SCARED = Screen for Child Anxiety and Related Emotional Disorders.

Table 2. RCI of the SCARED by Reporter.

Reporter RCI Pre Post Comparison of sessions

Child −1.98a 6 2 2 vs. 7 Father −2.47a 9 4 1 vs. 7 Mother −3.95a 10 2 1 vs. 7 Average −3.38a 9.5 2.67 1 vs. 7

Note. RCI = Reliable Change Indices; SCARED = Screen for Child Anxiety and Related Emotional Disorders. aClinically significant (greater than ±1.96).

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a substantial overnight component, while still requiring fewer days in the overall treatment approach.

The current study also indicates that parental involvement in brief, intensive therapies may be crucial to enact change. Although a comparator treatment without parents was not con- ducted, employing the parents in the treatment paradigm was essential to improve SepD in both the parents and the client. This case study indicates the importance of assessing parental anxiety and including parental tolerance of distress, autonomy, and parenting styles in the conceptualization of the case presentation of the child presenting for treatment. The parents in this study were also instrumental in setting goals, for themselves and for the child, and were able to help implement the treatment strategies at home as they were involved in the in-office didactic sessions.

The current study indicates that involvement of a clinical team may be beneficial in BITs instead of relying on one clinician alone. First, multiple clinicians were used in the current study to work with the parents and/or the child separately, in addition to providing precautions regard- ing safety and accountability during out-of-office exposures. Incorporating a clinical team of multiple, CBT-oriented clinicians allowed for the BIT format to be successful. Second, multiple clinicians were used during the assessment before the onset of treatment to better conceptualize Raj’s presenting behaviors. As the case conceptualization was a complex interplay of SepD and the previous ASD diagnosis, having a clinical team to aid in the conceptualization and distinction of symptoms was beneficial in treatment planning.

12 Recommendations to Clinicians and Students

Recommendations from the following treatment approach include adjusting duration, intensity, and parental involvement in current CBT approaches to SepD. Evidence from the current study indicated that substantial clinical progress could be made using brief and intensive therapies last- ing a duration of less than a week, with total hours hovering around 20 face-to-face hours. However, the effectiveness of this therapy has not been compared with treatment as usual, thus no conclusions can currently be made about its efficacy above and beyond standardized CBT approaches.

Primary caregivers should be included in BIT whenever possible. This treatment approach appeared to be efficacious with the involvement of both parents and may not be as effective if done without primary caregivers—although this is a hypothesis that was not addressed in the current work. However, previous works have indicated the importance of including primary care- givers in anxiety CBT treatments, especially the importance of addressing accommodating behaviors and anxiety experienced by parents themselves (e.g., Lebowitz, Wollston, et al., 2013). By addressing some of the parenting strategies, anxieties of the parents, and other cognitive skills (e.g., tolerating distress, promoting autonomy), greater strides in treatment goals can be secured— this appears to remain the case in brief, intensive treatments as well as weekly, manualized CBT treatments.

Conducting follow-up assessments after the completion of BIT is important, to evaluate degree to which gains are sustained. Significant symptom reductions from briefer interventions may, in fact, not be visible until months after the treatment, as evidenced in the current case study. If possible, follow-up assessments should be conducted at two time points to evaluate the lasting impact of treatment and to establish further goal setting and maintenance.

In addition, as symptom improvements were seen in the current case extending beyond the target diagnosis, it is recommended that follow-up assessments also be conducted with broad screeners of general psychopathology to understand the impact of treatment on other areas of life. An overall impairment rating scale provided by a blind rater would also be a recommendation of future studies.

98 Clinical Case Studies 19(2)

Finally, recommendations include promoting varied settings and having additional clinicians who are available to help during these brief, intensive treatments to be able to conduct sessions concurrently with parents and the client. Including varied settings may help generalize the learned skills and encourage greater external validity to replicate environments experienced by the client on the daily basis (e.g., a park, mall, restaurant). Furthermore, having multiple clinicians permits the introduction of unfamiliar people to enter the scene of treatment, which may increase the salience of the exposure. Thus, having a small team approach to conducing treatments is a recom- mendation for clinicians aiming to replicate or attempt brief, intensive therapies with clients and client parents.

Acknowledgments

The authors acknowledge and credit the family for their participation in this case study design, in addition to the many clinicians who assisted on this project (S. Ryan, A. Muskett, A. Tankersley, and R. Factor).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Tyler C. McFayden https://orcid.org/0000-0001-8942-1562

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Author Biographies

Tyler C. McFayden, MS, is a graduate student at Virginia Tech in the areas of clinical and developmental psychology. Her research and clinical interests include language development, autism spectrum disorders, social attention, and sex differences.

Susan W. White, PhD ABBP, is the Doddridge Franklin Saxon Endowed Chair in Clinical Psychology at the University of Alabama. Her program of clinical research addresses treatment development and optimi- zation for youth and adults with neurodevelopmental disorders.