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Annotated Bibliography: Treatment Therapies for Separation Anxiety Disorder (SAD)


Ehrenreich, J. T., Santucci, L. C., & Weiner, C. L. (2008). Separation Anxiety Disorder in

Youth: Phenomenology, Assessment, and Treatment. Journal of Behavioral Psychology 16 (3), 389-412.

The source is a literature review discussing the various assessment and treatment approaches for separation anxiety disorders in children. The journal’s major strength is its focus on evidence-based treatment approaches, such as Cognitive Behavior Therapy (CBT). This approach employs cognitive conditioning together with exposure techniques to enable patients cope with anxiety-triggering situations. In addition, CBT utilizes physical exercises to control physiological body responses to fear-arousing situations, such as muscle relaxation and breathing retraining. CPT often uses the Coping Cat program, a manual on intervention procedures for young people with anxiety disorders, including those associated with separation. The Coping Cat program incorporates “cognitive restructuring and relaxation training followed by gradual exposure to anxiety-provoking situations while applying the coping skills learned in previous sessions” (Ehrenreich, Santucci & Weiner, 2008, p. 396). The authors point out that while several studies have been carried out to determine the efficacy of CBT to treat anxieties in children and adolescents, there is limited literature regarding SAD patients below seven years. In this regard, the source is important as it focuses on a group of separation anxiety patients often ignored in controlled studies on the usefulness of Cognitive Behavior Therapy in the treatment of anxiety disorders associated with separation from parents. The source identifies family involvement as part of group interventions in treating SAD. It encourages parents to involve their children in social activities such as peer involvement, developing interpersonal skills, making friends, discussing fear-arousing situations, and learning from the experiences of friends.  These techniques help children to practice staying calm and relaxing when faced with difficult situations in the absence of their parents. In addition, it trains them to explore appropriate plans of responding to and coping with difficult situations.


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Hagopian, L. H., & Slifer, K. J. (1993). Treatment of Separation Anxiety Disorder with

graduated Exposure and Reinforcement targeting School Attendance: A Controlled Case Study. Journal of Anxiety Disorders 7 (3), 271-280.

The source discusses the use of gradual exposure techniques to deal with separation anxiety disorders in children. The authors used an evidence-based approach, which makes the article a very credible source of information on the treatment of SAD. The source discusses a case-study of a six year old girl diagnosed with SAD. She showed symptoms associated with anxiety disorders, such as school avoidance. The treatment therapy involved reducing contact with the mother during school attendance, accompanied with positive reinforcements. The researchers increased the amount of time the child spent away from the mother, such as encouraging her to commute to and from school alone. The researchers observed an improvement in the girl’s school attendance. Follow-ups after two and nine months indicated that the girl had maintained the treatment gains of the graduated exposure and reinforcement treatment modality.

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The source is important for two reasons. First, it attempts to determine the enduring effects of treatment therapies for separation anxiety disorders. The findings of the follow-up suggest that exposure to anxiety-arousing situations accompanied with appropriate reinforcements is an effective treatment of SAD in school going children. Consequently, the source provides a new insight for future studies on treatment therapies for anxiety disorders associated with separation. Specifically, it underscores the importance of post-treatment programs to assess the long term effectiveness of new treatment therapies. Second, the source distinguishes separation anxiety disorder from those associated with school and social phobias. This distinction helps to determine specific symptoms and treatment therapies for SAD. For instance, the source identifies separation anxiety disorder as a developmental disorder experienced in early and late childhood. Children with SAD usually have a strong attachment to their parents and often avoid attempts to separate them, such as reluctance to attend school. 

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Silver, R. R., Gallagher, R., & Minami, H. (2006). Cognitive-Behavioral Treatments for

Anxiety Disorders in Children and Adolescents. Journal of Primary Psychiatry, 13 (5), 68-76.

Cognitive-Behavioral Treatments for anxiety disorders incorporate treatment aspects borrowed from studies in behavioral therapy and cognitive psychology. The cognitive components of CBT include adjustment and psychopathology. In this regard, the source provides a hybrid approach to the treatment of anxiety disorders in children and adolescents. This model is based on the assumption that adolescents with anxiety disorders exhibit problems in three areas of functioning, namely:

  • The autonomic nervous system- they experience higher levels of physiological arousal in certain situations in anticipation to cope with the dangers/threats posed by those situations.
  • Cognition- they generate ideas associating the situation with danger, indicating that the physiological arousal is a signal of possible harm associated with that situation.
  • Behavior- in response to the physiological arousal and the associated perceptions of danger, adolescents resort to behaviors that could lead to avoidance or escape from the situations, but do so “in ways that hinder their functioning, or tolerate the situation with high levels of distress and discomfort that hinder concentration or effective performance in the situation” (Silver, et al, 2006, p. 69).

In this regard, Cognitive-Behavioral Treatments focus on developing coping skills that could enable adolescents function effectively in difficult situations without experiencing unnecessary distress or anxiety. CBT achieves this goal by seeking to improve physiological, cognitive, and behavioral functioning under challenging circumstances. Methods include identifying and understanding the nature of physiological arousal with the aim of helping adolescents exercise control over their autonomic nervous system as a way of reducing the rate of arousal. Cognitive methods focus on helping patients understand the content and nature of images, thoughts, and interpretation of anxiety-arousing situations. They are encouraged to challenge the accuracy and truth of their thoughts about situations as a means of internal coping. This source is unique because it focuses on a treatment approach that helps patients internalize situations and develop their own coping mechanisms. This is different from group interventions such as the FRIENDS program, which prescribes specific behavioral responses. Accordingly, the source provides a new perspective by underscoring the beneficial value of allowing patients take initiatives in dealing with anxieties.


Bogels, S. M., & Zigterman, D. (2000). Dysfunctional Cognitions in Children with Social

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Phobia, Separation Anxiety Disorder, and Generalized Anxiety Disorder. Journal of Abnormal Child Psychology, 28 (2, 205-211.

The source discusses the role of biased interpretation of situations in causing social phobia and separation anxiety disorders in children. The authors argue that negative interpretation of ambiguous situations creates fear in individuals. Negative interpretation occurs when the individual:

Ø  Overestimates threat, fear and danger,

Ø  Underestimates his or her ability to cope with dangerous situations

In this light, the authors argue that treatment of separation anxiety disorders should incorporate cognitive approaches aimed at discouraging “biased processing of ambiguous information” (Bogels & Zigterman, 2000, p. 205). In a research study to find out the connection between negative interpretation of information and separation anxiety disorders, the researchers exposed two groups of children to stories describing ambiguous situations. Both groups were then asked to give their interpretations of the stories using closed and open responses. The results indicated that children with anxiety disorders reported “more negative cognitions than control children” (p. 209).  Although anxious children did not exaggerate dangerous situations in their open responses, they overestimated them on closed responses. Compared to the control group, however, anxious children showed a tendency to underestimate their ability to handle dangerous situations on both closed and open-ended responses. These findings indicate that children suffering from separation anxiety disorders have “dysfunctional cognitions about ambiguous situations” (Bogels & Zigterman, 2000, p. 210). Accordingly, anxiety disorders can be treated by helping patients adopt a positive approach in interpreting situations.

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The research study contributes to the existing body of knowledge regarding the treatment of anxiety disorders by identifying the common personality trait in children with separation anxiety, generalized anxiety and social phobia. Anxious children tend to be afraid when exposed to social situations involving other people. The authors recommend a treatment therapy that focuses on psychological conditioning aimed at helping anxious children overcome irrational fears and instill a sense of competency to deal with potential dangers.

Shortt, A. L, Barrett, P. M, & Fox, T. L. (2001). Evaluating the FRIENDS Program: A

Cognitive-Behavioral Group Treatment for Anxious Children and their Parents. Journal of Clinical Child Psychology, 30 (4), 525–535.

The source is a discussion of a study carried out to evaluate the effectiveness of the FRIENDS program in the treatment of Generalized Anxiety Disorder (GAD), Social Phobia (SOP) and Separation Anxiety Disorder (SAD). The acronym FRIENDS stands for:

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F—Feeling Worried?; R—Relax and feel good; I—Inner thoughts; E—Explore plans; N—Nice work so reward yourself; D—Don’t forget to practice; and S—Stay calm, you know how to cope now (Shortt, et al., 2001, p. 526).

The source’s credibility is enhanced by the method of data collection, which informed the authors’ conclusions. The researchers carried out a Randomized Controlled Trial (RCT) experiment involving 71 children aged between six and ten years, and who had been diagnosed with SAD, GAD or Social Phobia. After a random treatment of the subjects, 69% of the children who had undergone the FRIENDS program “no longer met diagnostic criteria for an anxiety disorder at post-treatment compared to only 6% in the control group” (Short, et al, 2001, p. 532). The researchers also reported long term therapeutic gains in a follow-up assessment after one year.

The FRIENDS program is particularly useful because it not only details the importance of follow-up assessment plans, but also by outlining post-treatment therapies to guarantee long term success. In addition to the 10 weekly practice sessions, the program includes two “booster” sessions conducted one and three months after successful completion of treatment. The “booster” sessions are beneficial because they offer children extra opportunities to master the anxiety coping skills learned during the previous sessions. This kind of additional treatment is an important facilitation tool in helping children generalize the learned skills and use them to deal with the different anxiety situations they encounter in everyday life. This information is important in guiding future studies with regards to the persistence of treatment gains over time.

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Weems, C. F., & Carrion, V. C. (2003). The Treatment of Separation Anxiety Disorder

Employing Attachment Theory and Cognitive Behavior Therapy Techniques. Journal of Clinical Case Studies, 2 (188), 188-198.

The source focuses on group intervention by combining attachment theory and behavior therapy to treat separation anxiety disorder (SAD). This intersection of two approaches corresponds to the Cognitive-Behavioral Treatments, which also integrates two approaches. However, this approach differs from CBT in its employment of exposure techniques to help individuals develop appropriate mechanisms for coping with anxieties. In addition, it employs an evidence-based perspective in the treatment of a nine-year old boy with severe separation anxiety disorder.

The key aspect of CBT is the “graduated exposure to the feared stimuli or situation to extinguish anxiety and fear responses and foster development of coping skills” (Weems & Carrion, 2003, p. 192). On the other hand, attachment theory argues that a child develops insecure attachment to their caretakers when they are neglected, and their emotional needs are not met. Consequently, they experience anxieties when they are separated from their parents. This reaction is similar to that of children under exposure-based interventions during separation. Accordingly, attachment theory implies that a reinforcement of separation accompanied with responsive and positive interactions with affected children is highly useful in the treatment of SAD.

In this regard, this source is important to clinical research in psychology because it explores “a somewhat neglected but important intersection between behavior therapy and attachment theory in the treatment of SAD” (Weems & Carrion, 2003, p. 189). In particular, it highlights relevant areas where attachment theory can help develop useful strategies for implementing cognitive-behavioral interventions in the treatment of SAD.



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