Separation Anxiety Disorder:
A Case Study
Demet Çek
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PSI Child and Family Center
• Founded in 1992
• Believes that all psychological services regarding individuals,
families and children should be offered in the same system with
the cooperation of professionals in the field
• The staff includes pedagogues, counselors and clinical
psychologists
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PSI Child and Family Center
Provides:
• Child-centered family therapy
• Educational therapy & special education
• Play therapy
• Individual psychotherapy
• Couple therapy
• Seminars to improve parenting practices
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Mine Kayraklı Duman
 Boğaziçi University, Psychology
 Bilgi University, Clinical Psychology
 Works with children who have emotional difficulties
(anxiety, depression)
 Uses psychodynamic and cognitive perspectives
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Major Features for the DSM Diagnosis
of Separation Anxiety Disorder
Developmentally inappropriate and excessive anxiety concerning
separation from home or from those to whom the individual is
attached, as evidenced by three (or more) of the following:
1. Recurrent excessive distress when separation from home
or major attachment figures occurs or is anticipated
2. Persistent and excessive worry about losing, or about possible
harm befalling, major attachment figures
3. Persistent and excessive worry that an untoward event will lead
to separation from a major attachment figure (e.g. getting lost
or being kidnapped)
4. Persistent reluctance or refusal to go to school or elsewhere
because of fear of separation
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5. Persistent and excessive fear or reluctance to be alone or
without major attachment figures at home or to be without
significant adults in other settings
6. Persistent reluctance or refusal to go to sleep without
being near a major attachment figure or to sleep away from
home
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
* Three or more of the symptoms should be present for at least 4 weeks
for a positive diagnosis.
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Demographic Information
Date of Application: August 2008
Chronological Age: 3 years 8 months (born Dec. 2004)
The information was gathered from: Mother and father
of the child
The child lives with: Mother and father
Age, education level and jobs of parents:
Mother- 33 yrs old, college graduate, banking industry
Father- 35 yrs old, college graduate, banking industry
Siblings: Only child
Goes to a daycare center 5 days a week part-time
Has a nanny
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The Presenting Issue
 Time of Onset: A holiday with parents in summer when she was 2,5 yrs
old
 Constipation (kabız) during holiday and clyster (lavman)
 Poo on the carpets and Nazlı gets disgusted
 Restarts to poo in diapers
Goes to bathroom for pee
Gets used to new situations very slowly (ex: grandmother)
Temper tantrums when she can’t get what she wants
Doesn’t leave mom (ex: toys)
Has a constipation problem and gas pains.
Asks for milk around 5-6 o’clock in the morning.
Has been sleeping with her mom & dad since age 1.
• Symptoms appear both at home and at the nursery but at home they
are more severe
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The Presenting Issue
• No prior experience of psychopharmacological,
educational or psychological treatment.
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Family Profile
Father
• Had authoritarian parents.
• “I’m a soft dad.”
• “When I don’t do what she
wants, she wakes up 2-3 times
during the night.” *
• “Nazlı is a rigorous and
emotional girl. She likes
symmetry.”
Mother
• An apprehensive lady
• Gets upset even when
Nazlı hits somewhere
• Intrusive, perfectionist
• Had an intrusive,
overcontrolling mother. She
still has.
• Her mother thinks she
can’t take proper care of
Nazlı.
* Maternal separation anxiety leads to infant’s night waking
Guilt induction
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Social History
 Planned pregnancy
 Difficult pregnancy-the mother vomited until the 4th
month (bucket in the workplace)
 Stayed for 2 days at a hospital with a serum attached
 6th month she had a pregnancy diabetes
 Worried a lot about whether the diabetes would affect
the baby
 No medications used during pregnancy
 Had the labor when it was due
 Difficult labor but no complications
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Social History
 Relations with parents:
Parents are worried about her constipation
They always do what she wants
The parents do not set boundaries with her.
They don’t go anywhere without her.
• Relations with peers:
In the nursery, described as:
Having good relations with friends
Perfectionist
Rigorous
Orderly
by her teachers.
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Medical History
 No known physiological diseases
 No past operations
 No use of medicine
-> No underlying disease about bowel control
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Family History
 Nazlı’s father had constipation when he was younger
but it wasn’t as serious as Nazlı’s case.
 Nazlı’s mother was treated for depression for 5
months. Used Deprex (an antidepressant) during this
period.
 Mine Hanım referred the mother to another therapist
but she refused.
 Mother did not work in the first 6 months when Nazlı
was born.
 Anxiety increased when she started working.
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Family History
 She is worried about Nazlı going to primary school.
 She is afraid that someone might kidnap her when she
goes to school.
 Lack of self-efficacy as a mother because of her
relationship with her own mother
-> The negative attributions she makes keeps her from
separating from Nazlı.
-> There is an unspoken communication between parent
& child.
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Elaboration
 In terms of temperament, Nazlı is a child with low
adaptability (gets used to new situations slowly and
reacts when faced with change).
 Goodness-of-fit model: Parental responding
influences childs reactions which in turn affects
parents reactions.
Negative patterns are overly communicated in the
house (intrusive mother, low self-reliance)
 Research shows that low adaptability moderates
children’s responses to depressive familial
environments.
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Diagnostic Tools Used
 Play therapy
 Observation (video evaluation of unstructured and
semi-structured play with parents)
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Video Evaluation- The Marshack Method
 30 minutes of free-play with her mom
 20 minutes of semi-structured play with her mom
 30 minutes of free-play with her dad
 20 minutes of semi-structured play with her dad
Semi-structured play includes nurturing, setting
boundaries and challenging the child
Example: Asking Nazlı to make shapes from cubes and
observing how will her mother/father react if she
doesn’t do as they say. (setting boundaries)
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Video Evaluation
During the play, Nazlı cries about everything.
When she cries, her mother agrees to let Nazlı do what
she wants.
Permissive parenting style
Nazlı has control over her mother
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Video Evaluation
 During the play, mother & father had difficulty to
accept Nazlı’s negative feelings.
(ex: characters getting angry at each other)
• The feelings that come up during play reflect the
child’s feelings in the real world!
• If the child mentions it, it has to be a feeling that she’s
familiar to.
These can explain why the parents reject the child’s
feelings and change them into more positive ones.
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Video Evaluation
Understanding
& accepting
negative
feelings
“You look
worried”
Result:
The parent’s ability to set boundaries and read feelings need to
be improved.
They need to encourage the child to become more autonomous.
Nazlı’s parents are so protective & intrusive that they prevent
her development.
Connectedness-oriented parenting instead of autonomyoriented parenting
The process does not allow Nazlı to individualize and rely on
herself.
BUT also,
The child’s slow adaptability is very convenient to elicit such
behavior from her parents.
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Conceptualization
From a psychoanalytical perspective:
 Separating from poo = separating from her mother
• Separating from the period when:
Nazlı & her mother were a single body ( breastfeeding,
changing diapers etc.)
They used to share more than they do now
• Asking for milk: her oral needs have not finished yet
(although she was breastfed for about 8 months).
Actually, from a psychoanalytical perspective, if her oral needs
were not met, she either had to be eating a lot or very little.
Asking for milk is an excuse to check if her mother is still there.
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Conceptualization
From a psychoanalytical perspective:
Controlling the child’s poo = having control over Nazlı’s
body
The parents are so anxious over it that Nazlı becomes
anxious too.
Nazlı’s difficulties with defecating is a way of saying
“There are things that you can not control”
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Conceptualization
 Performance anxiety: (increases in the presence of her
mother)
I can’t draw.
I can’t play with legos.
Once, she wanted to throw away the picture she drew.
No tolerance for “the dirty things” that may
Associates
unwanted
come out of her.
things with
these
Poo= separation, control, “pis çocuk” (sümük, kaka)
What would they think of me if I let dirty things out?
-> Low self-esteem
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Conceptualization
 When she expresses a negative feeling in a play with
the therapist, she goes inside to check her mom
(sometimes brings her inside).
“The parents can’t find the baby bear.”
 To check if what comes out of her mouth hurts her
mother
 Worried about her mother’s well-being
ex: When her mother takes a shower, she goes in the
bathroom to see her if she doesn’t come out in 10
minutes
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Conceptualization
 The primary problem was about the poo.
 Cognitive-behavioral methods could work here.
 However, first, the dynamics in the family have to be
dealt with.
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Treatment
 Suggestion to the family: to start working with the
parents & then including Nazlı in the sessions
 Cognitive & analytical methods with the family
 Talk to them about how they should set boundaries
 About their own childhoods
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Family Sessions with the parents
• Why are they sleeping with Nazlı?
They feel guilty (especially the mother) about working.
To compensate for their lack of time together, they sleep
with her.
Sleeping together serves a cause for the whole family.
BUT no boundaries, no generation difference
Children need their instincts to be controlled by parents.
Thus, For Nazlı, the situation is like “driving when all the
lights are yellow”.
Separation anxiety is not one-way. The mother also has
to be ready to separate from the child.
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Conceptualization &Treatment
 Nazlı was 3 yrs 8 months old before the intervention of
separating beds. She was in the Oedipal stage.
 Example behaviors:
- intervening when mom & dad hug each other
- “ Kiss me like you kiss mommy” (importance of
setting boundaries)
 Sleeping with parents for Nazlı was a way to:
- compete with her mom
- control parent sexuality
- realize the imaginary marriage with her father
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Family Sessions with the parents
 Intervention: the beds separated
Method: “control crying”
Resembles systematic desensitization
A cognitive-behavioral method used
In 1 week, the problem was solved.
The parents confessed:
“She didn’t have any difficulties about sleeping apart.
Maybe we weren’t ready to sleep without her.”
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Conceptualization &Treatment
 Intervention:
The parents are given homeworks (readings etc.)
The family’s obsessive nature was convenient for
homeworks.
These served to educate the family about parenting &
child development.
To create a change in their thinking style -> cognitive
intervention
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Sessions with parents & Nazlı
 5th session. Intervention:
Every day at a specific time, she will sit on the toilet
with her dad and wait.
The therapist explained this system to Nazlı.
Gets a reward if she tries.
Did not work out.
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The Current Situation
 A week ago:
Tells that she needs to poo
The family puts the diapers on
Makes the poo in another room by herself
• Now:
She makes the poo with the diapers on, on the toilet by
herself
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Future objectives
 Getting Nazlı to poo in the toilet before she starts
primary school
 Getting Nazlı’s mother to acknowledge her anger
towards her and to become acquainted with her
destructive feelings
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From a developmental
psychopathology perspective:
 Separation anxiety occurs in children because
attachment is necessary for human survival.
 Environment full of dangers, strangers
 Until the child learns what to expect, the environment
is unpredictable.
 After those expectations become manifest, the norm
for separation anxiety is to decrease and eventually
disappear.
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From a developmental
psychopathology perspective:
 Sleeping with parents can be considered normal for a
child in rural part of the city or in eastern countries.
 This high SES, Caucasian family adopts the western
lifestyle in a city setting. Identified with the West
 Thus, it’s important for the child to have autonomy.
 Sleep arrangements are not a problem if there was no
anxiety issue.
 In this case, Nazlı can’t do anything without her
parents. Toilet training problems etc. So, here it’s
problematic.
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From a developmental
psychopathology perspective:
 Internalizing behavior is more acceptable for girls than
for boys.
 If she were a boy, they may not have brought her to the
therapist.
 Conceptulization and treatment used analytical and
behavioral perspectives.
 Family systems theory?
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Family systems theory
 It argues that children’s symptoms are reflective of
interaction patterns in the family. Symptoms may
serve a purpose of maintaining harmony and avoiding
conflict between other family members.
 Children’s SAD was found to be correlated with family
disharmony and parental inconsistency.
 When a family component was added to CBT for
treatment of a child’s anxiety disorder, the results are
longer lasting compared to CBT only groups.
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Family systems theory
 Family systems theory would identify the underlying
mechanisms and solve the deep-routed conflicts.
 Cognitive methods are symptom oriented. They
solves the problems that come up at each
developmental level.
 If the problems which come up today are solved,
what will happen when other problems come up at a
different developmental level?
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Multiple Family Processes in Children
of Depressed Parents
 Examples of children with depressed parents show
that:
Patterns of adaptation and maladaptation have multiple
sources within the family and the individual
A narrow view focusing on only one familial, or
individual, factor is likely to be misleading about the
course of children’s development in these families. 5
Ex: dysfunctional marital relations
problematic parenting
genetic inheritance
Complex patterns of
social & emotional
family processes
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Multiple Family Processes in Children
of Depressed Parents
 Parental depression contributes to insecure parent-
child attachment which increases the child’s risk for
the development affective disorders.
Recent studies show that parental depression may be
causally related to insecure attachment.
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Emotional Security Hypothesis
 Children of depressed parents grew up in family
environments with parental inconsistency, emotional
unavailability and marital conflict.
 Risk for insecure attachment
 Adjustment problems
 Emotional insecurity may be a mediator of these
children’s risk for adjustment problems
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Emotional Security Hypothesis
 Increases in emotional insecurity alter children’s
functioning so that maladaptive responses become
more appealing.
 Disturbances in attachment are important in the
development, maintenance and intergenerational
transmission of depression in families.
 Familial patterns of dysfunctional communication &
psychological unavailability leads to emotional
security concerns for children of depressed parents.
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Discussion
 Psychoanalytic formulation, cognitive-behavioral
interventions
 What other functions may constipation have for
Nazlı?
 Compared to the previous case study presentations,
what are the protective factors for Nazlı?
Family accepts to be a part of the treatment. They
are eager to cooperate with the therapist (High SES)
No problem behavior at the nursery
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Thank you for listening!
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