Ramesh K.Jainy John

Aruna SudarshanJincy Jacob

N. ShivashankarNIMHANS,

Bangalore - 560 029

Communication Impairment inSeparation Anxiety Disorder (SAD) -A Case ReportAbstract: Separation anxiety disorder (SAD) refers typically to younger children whoare extremely unwilling to separate from major attachment figures or from home.When this behavior persists well past three years of age. (particularly up to six yearsand beyond), the normal phose of separation anxiety turns out into something awayfrom the normal, which is termed as separation anxiety disorder. The classical signsand symptoms of this disorder are: reluctance to fall asleep without being near theprimary attachment figure, excessivedistresswhen separation is imminent, nightmaresabout separation-related themes, homesickness and frequent physical or somaticsymptoms. They may also be associated with inadequate communication skills.

We present here a case report of a girl aged 4 years born of a non-consanguineous marriage hailing from a nuclear family of middle socioeconomicstatuswith no significant family history, Shewas diagnosed to have separation anxietydisorder (as per DSM IV) with communication impairment by the child psychiatristand was referred for speech/language assessment and intervention. On evaluationthe child was found to have inadequate communication skills with receptive languagebetter than the expressive language. The child showed excessive pathologicalattachment with the mother resulting in poor socialization thus limiting the child toexplore the communication world. The intervention program instituted in this childover a period of three months has revealed a significant progress in the overallbehavior of the child as well as in the communication skills.

Introd uction

The term separation anxiety refers to the anxiety, which weface when we are going to be separated from our loved ones(Even if it is for a brief period of time). We as adults express

our feelings covertly, hut children tend to express their feelings moreovertly and they are prone to be more vulnerable to the process ofseparation.

According to most experts, separation anxiety is a natural eventin human development. It begins at around eight months, wheninfants start differentiating between objects in the world. At this time,a child begins to understand that objects exist even when theydisappear from view. During this period when children start noticingthe absence of parents from their visual field, they start developingthe process of separation anxiety.

Traditional observation is that the child can usually be calmedby a loving person, regardless of relationship, except for a normalperiod of "stranger anxiety" from about 7-12 months. During theperiod of 18 months to 3 years the child feels anxious when theparents leave but can be distracted by activities. During day careschool or pre-school period, crying is common, and usually stopsafter the parent has gone and the child gets involved in activities,and from 4-5 years and there after most children are secure enough

Communication Impairment in Separation Anxiety Disorder (SAD) - A Case Report 59

to leave their parents with no distress (Stevenet al. 1998).

If these behaviors - and the anxiety behindthem - continue well past three years of age(particularly up to six years and beyond), thenthe normal phase ofseparation anxiety turns outinto something away from the normal which istermed as separation anxiety disorder.

Separation anxiety disorder refers typicallyto younger children who are extremelyunwilling to separate from major attachmentfigures (e.g. parents, grandparents, oldersiblings etc.) or from home (DSMIV 1994).

The prevalence rate reported globally islower than 2% in general population andequally reported to be prevalent among boysand girls. The most common age at which thedisorder is identified is at 11 years during whichmost of the children are in 6th grade (Paul, 1989).

Extremely rare instances ofmortality occurin severe separation anxiety.Mortality generallyresults from associated major depression thatmay lead to suicide. Long-term follow-upstudies of children successfully treated forschool refusal because of separation anxietyshow some children with continued impairmentof social functioning (i.e., social and affectiveconstriction) despite having returned to school;this may reflect the long-term impairment andmorbidity in this disorder. No specificdifferences in prevalence rates are noted forspecific racial or cultural groups; however,somewhat increased incidence has beenreported among families of lowersocioeconomic status as well as single parentfamilies. The prevalence of school refusal wasreported to be equal for boys and girls (Granellde Aldaz et al. 1984).

The classical signs and symptoms ill thisdisorder are: reluctance to fall asleep withoutbeing near the primary attachment figure,excessive distress (e.g., tantrums) whenseparation is imminent, nightmares about

60 Journal of the Indian Speech and Hearing Association, 2007, Vol. 2 J

separation-related themes, homesickness (i.e.,a desire to return home or make contact withthe primary caregiver when separated),frequent physical or somatic symptoms such asabdominal pain and palpitations (Bowly,1987).

The causes of separation anxiety disorderhave been broadly classified into psychologicaland the biological.

In the psychological sphere, experts havepostulated that early and traumatic separationfrom the attachment figure (as well as a familyhistory of anxiety disorders or depression infirst-degree relatives) may increase thelikelihood of the child and, later on, theadolescent or adult developing separationanxiety disorder. Examples of early andtraumatic separation include a prolonged stayaway from the primary caregiver during theneonatal period, later sudden hospitalization,and early loss of attachments because of deathor divorce (Keable, 1997).

Chronic stress affects brain areas involvedin learning and emotional responses. Thesealterations have been related with thedevelopment of cognitive deficits. Thebiological hypothesis proposes that thehormonal changes under stressful conditionmay increase the activation of amygdala and inturn suppress the activities of the frontal lobe,which may result in the likelihood of thesedisorders. Since,both amygdala and the frontallobe are hyper and hypo activated respectivelyin the stressful conditions, it may result inimpaired emotional behavior (increasedanxiety) and learning respectively (Keable,1997). Dagnino-Subiabre et al. (2005),in theirexperimental study on rats found stress induceddendritic atrophy in inferior colliculus neuronswith no neuronal morphological changes in thesuperior colliculus. They have also observedthat stressed rats showed a stronger impairmentin acoustic conditioning than in visualconditioning. They further reported, fifteen

days post-stress, the inferior colliculus neuronscompletely restored their dendritic structure,showing a high level of neural plasticity that iscorrelated with an improvement in acousticlearning. These results suggest that chronicstress has more deleterious effects in thesubcortical auditory system than in the visualsystem and may affect the aversive system andfear-like behaviors. These studies point to thedysfunction in both cortical and subcorticalstructures when under stress which mightnegatively influence the development ofcommunication.

To our knowledge there seems to be noliterature available on the communication skillsin these children. We present here a case reportof separation anxiety disorder in relation tocommunication impairment.

Case report:

A girl aged 4 years born of a non-consanguineous marriage hailing from anuclear family of middle socioeconomic statuswith no significant family history was broughtto the hospital with the complaints ofinadequate speech, poor attention and excessiveclinging behavior. She was diagnosed to haveseparation anxiety disorder (as per DSMIV)by theDepartment of Child Psychiatry and wasreferred to the Department of Speech Pathologyand Audiology for her communication deficitsand therapeutic intervention. Pre, peri andpostnatal history revealed no significantcomplications.

As reported by parents, the child generallyexhibits behaviors like excessive crying,nocturnal enuresis, disturbed sleep, clingingbehavior towards the mother and excessivedistress.

Speech and Language evaluation:

Oral speech mechanism was normal. Herattention was inadequate and could notconcentrate on an activity for more than 30

seconds. The child would not sit alone, andwould always sit on the mother's lap and anyactivity would be done only with her left handwhile her right hand clutched her mother'sdress. The child had eye contact but would notmaintain it for more than one second. The childhad normal hearing as per the auditorybrainstem response report done elsewhere.Clinical observation and interaction with thechild demonstrated normal hearing.

Comprehension:

The child was able to follow single stepcommands mostly when accompanied bygestures and/or when accompanied bycontextual cues. She was able to identify mostof the gross body parts. She also had the conceptof possessives and could comprehendpsychological shades of the speaker. Shecomprehended few common objects and fooditems that she consumed on a daily basis, as wellas lexical categories such as a few animals,vehicles, fruits, vegetables, and positions. Shealso had good object manipulation skills.

Expression:

The child could express through jargon aswell as single word utterances along with fingerpointing. She had a vocabulary of 8-10 words,which was inconsistent.

Therapeutic intervention:

The child attended 3 months of speech andlanguage intervention program and was seen 3times a week.

The goals worked upon were rapportbuilding, improving the pre-requisites oflanguage, vocabulary building, comprehensionof simple verbs and social interaction skills bygradually weaning the child away from themother. The program incorporated theprinciples of play therapy, systematicdesensitization and relaxation techniques. Theprogress made by the child over a 3-monthperiod is depicted in Table 1.

Communication Impairment in Separation Anxiety Disorder (SAD) - A Case Report 61

.uoie I: Uepicting the progress of the child over a span of three months of Speech-Language intervention.

Sr. No. Goals Progress (1 sl Month) Progress (2nd Month) Progress (3rd Month)

1. Attention span < 5 seconds. Progressed to about 15 mins Progressed to about 25 mins

2. Sitting behavior Minimal; sits for about Sits for about 40 mins on the Sits for about 1 hour. The child

20 minutes on the mother's mother's lap and would stand would also stand up, walk around

lop after which she would up occasionally keeping the room and away from the

start crying. a minimal distance mother, when engrossed in

from the mother. the activity.

3. Eye contact Gives eye contact consistently Gives eye contact consistently, Gives and maintains for about

but does not maintain it. but maintains inconsistently . .. a brief period consistently.

4. Cry behavior Cried throughout the whole Cried during the initial Cried only during the initial 5 minutes

session (40-45 minutes) 15-20 minutes of the session. of the session, later the child used

to get engrossed in the ploy activity.

5. Ploy behavior No ploy behavior observed, Self-play was observed Self-play and parallel

the child used to observe the to be present. play present.

parents playing with thetherapist, but inconsistent.

6. Anxiety The child would give eye gaze Eye gaze present even when Anxiety reduced as she got more

to the' mother even when she gets out of the mother's involved in play activity; vocalization

seated on her lap to ensure lap and stands; if the distance increased, she was able to walk

her presence. between them was more, around in the room without

she would start crying and looking at the mother; the child

would also start crying did not cry when the door was closed.

when the door was closed.

7. Social interaction Hardly present. The child was able to give social Socializes even with

skills. smile to the therapist whom she strangers, would shake hands,

was familiar with, but would start kiss, soy bye ele

crying as soon as a stranger

enters the room.

S. Vocabulary Comprehension and Comprehension and Comprehension and

expression of 10- 12 words expression of 15- 1S words expression of 20-25 words

9. At home Mother hod to be with the child Mother could leave the Mother could leave the child

in the some room; and hod child for a short period and carry out her household

difficulty in carrying out the of time independently. activities for a long period of

household activities leaving time and the child would not be

the child. disturbed if the mother left her alone.

DiscussionThe present case report highlights the

important role ofSpeech-Language Pathologist.Communication impairment appears to be oneof the main features of Separation AnxietyDisorder and can be expected to be present dueto impaired, ?iological function impeding thecommunication development. Languagedevelopment is an active social process wherethe child experiences language in contextualenvironment. Since these children haveimpaired socialinteraction or limited interactionwithin immediate surroundings, the

communication development often suffers. Inaddition the pathophysiological basis of anxietydisorder would itself influence and impaircommunication development.

Anxiety elicits stress response, whichreleases a group of neurotransmitters calledcatecholamines (dopamine, epinephrine, andnor epinephrine) into the central nervoussystem. Catecholamines effectively If'turn on'our heart muscles and "turn off" the stomachto prepare for 'fight or flight responses" (Lukel,1978).

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Interestingly, these same neurotransmitters,"may turn on a structure called the amygdala(the brain region that is responsible for fear){Figure1L and turn offthe prefrontal cortex (thebrain region where thinking occurs) {Figure2Lallowing posterior cortical and sub corticalstructures to control our behavior." In otherwords, under these conditions, we stop beingrational and are only emotional (fearful)whichaffectsmemory.

Figure 1: Depicting the activation of amygdala in ananxious individual.

Figure 2: Depicting the suppression of the frontal lobe inan anxious individual

Emotional data also takes high priority.When an individual responds emotionally to asituation, the older limbic system (stimulatedby the amygdala) takes a major role and thecomplex cerebral processes are suspended.Anger, fear of the unknown, or joy, quicklyoverrides the rational thoughts. This overrideof conscious thought can be strong enough tocause temporary inability to talk ("I was dumbfounded) or ("I froze"). This happens because

the hippocampus is susceptible to stress,hormones, which can inhibit cognitive fixing;long-term memory and learning. Hart (1983)calls this process as II down shifting". Everyindividual is confronted with anxious situationsin their lives, which prevail for a temporaryspan of time, but in a case of separation anxietydisorder, the anxiety exhibited by the child isgrown to a chronic extent that it eventuallyimpairs the communication abilities. {Figure3}

Figure 3: Flow chart depicting how the learning andcognition might be impoired when an individual isconfronted with anxiety.

Thus the pathological loop maybe the basisof communication impairment in children withSAD. Implementation of methodical trainingprogram can influence and enhance thecommunication development and graduallyrelieve the anxiety behavior. Play and rapportbuilding techniques were instrumental ingradually changing the behavior in the presentcase. This report focuses on the issue ofidentification of communication deficits andtherapeutic management in children with SAD.

The main role of a speech languagepathologist in treating the SAD includes theassessment and carrying out of a tailor madetherapeutic program, which would aim atimproving the communication skills andcounseling the parents regarding the realisticprognostic expectations. One important issue,which needs to be talked to parents, is the riskof child becoming learning disabled.

In terms of therapeutic aspects the main roleof a Speech Language Pathologist would not

Communication Impairment in Separation Anxiety Disorder (SAD) - A Case Report 63

only be restricted to improve the adequacy ofcommunication skills of the child, but also toreduce the undesired behaviors of the child (likethe chronic clinging behavior of the childtowards the mother etc), and to generalize themacross the clinical settings thereby making thechild more sociable.

ConclusionThe present case report highlights the

importance of knowing the pathophysiology oflanguage impairment in children with SAD.This knowledge would help the SpeechLanguage Pathologist in better managementand effective guidance to.parents. Treatment ofSAD calls for a multi disciplinary approachinvolving Psychiatrist, Psychologist, and SpeechLanguage Pathologist.

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