EDUCATION AND TREATMENT OF CHILDREN Vol. 27, No. 1, FEBRUARY 2004 The Use of Differential Reinforcement and Fading to Increase Time Away from a Caregiver in a Child with Separation Anxiety Disorder William A. Flood and David A. Wilder University of the Pacific Abstract The use of differential reinforcement of other behavior (DRO) and fading of time away from caregivers in an 11-year old boy with Separation Arviety Disorder (SAD) is illustrated. Dur- ing baseline, the participant exhibited emotional behavior (i., crying, whining, asking to contact parents) as soon as his caregiver left the therapy room. During intervention, the par- ticipant was given access to preferred items contingent upon the absence of emotional behav- ior during time away from his mother. A changing criterion design was used to evaluate intervention effects, Results indicated that the intervention was successful in increasing the amount of time the child was able to be away from his mother without exhibiting emotional behavior. DESCRIPTORS: differential reinforcement of other behavior (DRO), emotional be- havior, fading, separation anxiety disorder. wk ke When child protests (i.e., cries, whines, whimpers, etc.) upon separation from a parent or other caregiver are excessive and persist over time, Sepa- ration Anxiety Disorder (SAD) may be diagnosed. SAD is characterized by an abnormally heightened fear response to real or imagined separation from parents and/or other caregivers. Other criteria for a diagnosis in- clude a duration of the disturbance of at least 4 weeks, onset before age 18, and the presence of clinically significant distress or impairment in social, academic, or other areas of functioning (American Psychiatric Association, 1994). The activities of children with separation anxiety disorder can be severely limited because these children often insist on remaining in close physical proximity to a caregiver. In addition, this disorder may make it difficult for parents and other caregivers to enjoy their own independent activities due to constant worry about their children when separated. Author Notes: Requests for reprints should be addressed to David A. Wilder, Depart- ment of Psychology, University of the Pacific, Stockton, CA 95211. Address Correspondence to: David A. Wilder, Department of Psychology, University of the Pacific, Stockton, CA 95211, dwilder@uop.edu, (209) 946-7317. Pages 1-8FLOOD AND WILDER Reports of the prevalence of SAD range from 2.7% to 4.5% in children and young adolescents (Masi, Mucci, & Millepiedi, 2001). There is also some evidence that children with SAD are disproportionately diagnosed with a variety of anxiety disorders in adulthood. In one longitudinal prevalence study, 83% of participants who received a diagnosis of juvenile separation anxiety disorder also received a diagnosis of an anxiety and/or depressive disorder as an adult (Silove, Manicavasagar, & Drobny, 2002). Although many mental health professionals view SAD as an unlearned “disorder of attachment,” research has suggested that parents and caregivers may inadvertently teach their children to behave in this manner by delaying their departure, returning, or reasoning with their child con- tingent upon protests (Gewirtz & Pelaez-Nogueras, 1991; Gewirtz & Pelaez- Nogueras, 1992). Gewirtz & Pelaez-Nogueras (1992) experimentally dem- onstrated that contingent attention increased protesting behaviors in young children. They further demonstrated that noncontingent attention deliv- ered by parents while they were leaving decreased separation protests in these same children. The treatment of SAD has taken two general approaches: pharmaco- logical and behavioral. Pharmacological treatment has included the use of antidepressants such as imipramine (Klein, Koplewicz, & Kanner, 1992) and fluvoxamine (Pine, Walkup, & Greenhill, 2001). Even though some studies have shown these drugs to be effective (Gittleman-Klein, & Klein, 1971; Pine et al., 2001), pharmacotherapy is generally suggested for use after behavior therapies have failed or in combination with behavioral tech- niques, although patients are probably more likely to receive drug treat- ment alone than any other form of treatment (Masi et al., 2001). Interest- ingly, there have been reports of the antipsychotic medication resperidone actually increasing symptoms of SAD in some children (Hanna, Fluent, & Fischer, 1999). Although there have been some uncontrolled case studies of the suc- cessful behavioral or psychosocial treatment of SAD (e.g., Hamilton, 1994; Levine, Ashmore-Callahan, Kendall, & Ichii, 1996; Zamudio & Wolfe 1996), only a couple of controlled studies evaluating nonpharmacological treat- ments of SAD exist. Ollendick, Hagopian, and Huntzinger (1991) used a multiple baseline across participants design to evaluate a behaviorally based intervention to increase the amount of time two children with SAD slept apart from their mothers. The intervention, which consisted of contingent access to preferred items/activities and a self-control training procedure, was successful; participants no longer met criteria for SAD upon its comple- tion. Hagopian and Slifer (1993) employed contingent access to preferred items and graduated exposure to separation to treat SAD in a six-year old girl in a school setting. These authors used a changing criterion design to demonstrate treatment effects. The purpose of the present study was toTHE USE OF DIFFERENTIAL REINFORCEMENT 3 add to the literature on the treatment of SAD by replicating the procedure used by Hagopian and Slifer (1993) in an outpatient setting, Method Participant and Setting George was 11 years old and had a diagnosis of Separation Anxiety Dis- order and Attention Deficit Disorder, Inattentive type. These diagnoses were given months before this study took place by a psychiatrist at a university affiliated teaching hospital. Diagnoses were made with the assistance of a clinical interview and parent rating scales and were based on DSM-IV (American Psychiatric Association, 1994) criteria. At the time of the study, George continued to meet all of the criteria for both of these diagnoses. Upon mention of a separation from a parent (other than the daily separa- tion that occurred when George went to school), George would cry, scream, and plead for the caregiver not to leave. At the time the study began, George had been away from both caregivers simultaneously only very rarely (i.e., in emergencies for very brief time periods). George was on the drug Tofranil® for months prior to the start of this study and he remained on a constant dose (i.e., 25 mg) of Tofranil® for the duration of the study. George was developmentally normal and of at least average intelligence. All sessions took place in a therapy room at a psy- chology clinic affiliated with a university. The therapy room was approxi- mately 3m X 3m and included a table and two chairs. The room was also equipped with a one way mirror. Dependent Variable and Data Collection The main dependent variable was latency to emotional behavior, which was defined as asking for contact with one or both parents two times and/ or crying (ie, the presence of visible tears). George exhibited no other forms of emotional behavior. Sessions were conducted in which the participant's mother left his sight and moved varying distances away from him for in- creasing, periods of time. George’s emotional behavior in response to his mother’s reported distance away from him was also assessed. Session du- ration ranged from 3 to 90 minutes. Goals for time and distance away were generally doubled after at least two successful sessions. Trained research assistants recorded data on a structured data sheet. A stopwatch was used to determine length of sessions. Sessions were conducted two times per week for 23 weeks. One session was conducted each time George visited the clinic.4 FLOOD AND WILDER Experimental Design and Independent Variable A changing criterion design was used to evaluate intervention effects. The independent variable consisted of differential reinforcement of other behavior (DRO) (i.e., access to preferred items /activities contingent upon the absence of emotional behavior for varying periods of time) and sys- tematic increases in the amount of time George was separated from his mother and reported distance from his mother. Procedure An initial interview, which was conducted with George and his par- ents, focused ona description of the conditions under which George would exhibit extreme emotional behavior. After reviewing the interview data, it was hypothesized that George's emotional behavior was maintained by positive reinforcement in the form of attention from a caregiver (i.e., the continued presence of a caregiver reinforced the behavior). However, no formal data (other than that provided during the interview) were gath- ered to support this contention. Stimulus Preference Assessment. Before sessions began, a verbal paired stimulus preference assessment (Northup, George, Jones, Broussard, & Vollmer, 1996) was conducted to determine George's preferred items/ac- tivities. Three items were identified and used: 30 minutes of access to video games, a small piece of candy, and a coupon that could be exchanged for a gift certificate at a local toy store. Baseline. During baseline sessions, George was escorted into the therapy room. George and his mother were the only people in the room; the ex- perimenter observed behind the one-way mirror. George’s mother then told him that she had “something to do”, and that she would be back soon. George's mother then attempted to leave the room. When George exhib- ited emotional behavior, his mother remained in the room and consoled him (ie., touched his shoulder, told him that she was “right here”) until his emotional behavior stopped. Intervention. During intervention sessions, George was escorted into the therapy room. George and his mother were the only people in the room; the experimenter observed behind a one-way mirror. At the start of each session, the experimenter and George negotiated the amount of time away from his mother and his mother’s distance from the therapy room. The experimenter developed these goals before sessions began. A minimum of two consecutive successful sessions at the previous goal level was required before the goal was increased. When goals were increased, they were usu- ally doubled. However, on some occasions, goals were intentionally de- creased. This was done in order to demonstrate experimental control. That is, this return to lower goals (and the corresponding change in George'sTHE USE OF DIFFERENTIAL REINFORCEMENT 5 behavior) helped to verify that George’s behavior was controlled by the goals set, and not by some other variable (see Hall & Fox, 1977 for a de- tailed justification of this technique). At the start of a session, the experimenter asked George if he believed he could achieve the goal (e.g,, “George, the goal for today is 24 minutes. Do you think that you can remain apart from your mother for 24 min- utes?”). If George said yes, the goal was used. If George said no, the goal would have been modified according to what George believed he could successfully accomplish. However, George never disagreed with a goal presented by the experimenter. The experimenter then read the partici- pant a script detailing the contract. The script included a statement indi- cating that if George did not exhibit crying, whining, or other emotional behavior and did not ask for his mother to return before the specified amount of time had elapsed, he would get access to his preferred items immediately after the session ended. The script also described what would happen if George did exhibit emotional behavior and how George could immediately access his mother via a cell phone that the experimenter kept with him at all times. A session began when George’s mother left the room. At that time, a timer was set to count down the time remaining in the session, The timer was placed in George's view on a desk in the therapy room in which ses- sions were conducted. During sessions, George worked on math facts (these were usually part of his homework for that day). George also occasionally took a restroom break or water fountain break during sessions. When he needed to use the restroom or get a drink of water, he was instructed to say so. At that time, the experimenter entered the room and escorted George to the restroom or water fountain. George occasionally asked the experi- menter when his mother was returning during restroom/water fountain breaks. When asked, the experimenter told George the amount of time remaining in the session (e.g,, “Your mother is away for 90 minutes today. Since 40 minutes have elapsed, she'll return in about 50 minutes”). A ses- sion ended (and George’s mother returned) when the predetermined ses- sion duration was met or when George exhibited emotional behavior. When George did exhibit emotional behavior, his mother was contacted on a cell phone and was asked to return to the room. If George did not exhibit emo- tional behavior during a session, he received access to all of his preferred items immediately after that session ended. George did not receive access to these items if he engaged in emotional behavior before the session time had expired. Interobserver Agreement (IOA) An independent observer sat behind the one-way mirror and collected IOA data on the presence of emotional behavior during 100% of sessions. An agreement was defined as both observers scoring an instance of emo-6 FLOOD AND WILDER tional behavior within 5 sec of each other. Agreement was determined by dividing the number of agreements by the number of agreements plus dis- agreements and multiplying by 100%. Agreement averaged 100% Results The top panel of figure 1 depicts minutes without emotional behavior. During baseline, George exhibited emotional behavior immediately upon his mother’s attempted departure (M = 3 sec). During intervention, George did not exhibit emotional behavior and attained the goal for every session except one (session number 30). Eventually, George was able to be away from his mother for 90 minutes without exhibiting emotional behavior. 3 i 2 = I Distance (in feet) Session Figure 1. Minutes without emotional behavior while George’s mother is out of the room. (top panel). George's mother’s reported distance from therapy room (bottom panel). Solid lines in data represent jointly established therapist /participant goals The bottom panel of figure 1 depicts George's mother’s reported dis- tance away from the therapy room. During baseline, George’s mother re-THE USE OF DIFFERENTIAL REINFORCEMENT 7 mained in the room with George. During intervention, George’s mother gradually increased her distance from the therapy room. By session 23, she left the premises altogether. George’s mother reported that the same procedure was implemented at home and that it was effective in increas- ing time away from both her and George's father. Discussion The results of this study provide further evidence that with sufficient reason to refrain from emotional behavior and systematic fading of caregiver separation, a child with SAD can learn to tolerate prolonged ab- sences from caregivers. Because parents of children with SAD are often reluctant to leave their children, changing parental behavior may be an especially important component of treatment for children with SAD. In the present study, George's mother reported that she was very anxious when she left George in the therapy room. Towards the end of the study, she reported a decrease in her own anxiety level when she left George. Practitioners should be aware of this aspect of the treatment of SAD and plan intervention accordingly. A couple of limitations of this study should be noted. First, the inclu- sion of a single participant limits the extent to which results can be gener- alized to other children with SAD. Second, although George's parents re- ported that upon completion of the study they successfully and routinely used the procedure when leaving George at their house, no data were col- lected to verify this. Three areas of future research are suggested. First, research on the treat- ment of SAD might focus on replicating, on a larger scale, the few single subject design studies that exist. Future research is also needed to deter- mine how critical fading of separation and access to preferred items/ac- tivities are to treatment success. Alll of the previously published studies on interventions for SAD (e.g., Hagopian & Slifer, 1993; Ollendick et al., 1991) have employed both of these treatment components to some extent. A treat- ment component analysis is needed. Finally, future research on the assessment and treatment of SAD should focus on the conduct of pre-intervention functional assessments of the be- haviors that comprise this diagnosis. Although the function of crying and other emotional behavior upon separation from a caregiver may seem ob- vious (i.e., maintenance via social positive reinforcement in the form of access to a particular type or duration of social interaction), this may not always be the case. It is conceivable that other functions (e.g,, social nega- tive reinforcement in the form of avoidance or escape from separation) may be involved in the maintenance of common SAD behaviors. In these situations, functional assessment data would be useful in guiding treat- ment selection.8 FLOOD AND WILDER References American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), fourth edition. Washington D.C.: APA Press. Gewirtz, J. L., & Pelaez-Nogueras, M. (199 1). The attachment metaphor and the conditioning of infant separation protests. In J. Gewirtz and E. Kurtines, (Eds.), Intersections with attach- ‘ment. Hillsdale, NJ: Lawrence Erlbaum Associates, Gewirtz, J. L,, & Pelaez-Nogueras, M. (1992). Infants’ separation difficulties and distress due to misplaced maternal contingencies. In T, M. Field, M. McCabe, and N. Schneiderman (Eds.), Stress and coping in infancy and childhood, Hillsdale, NJ: Lawrence Erlbaum Associ- ates. 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