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CHAPTER 37 • Mental Disorders of Childhood and Adolescence

BOX 37.11

Therapeutic Dialogue: Tics and Disruptive Behaviors

INEFFECTIVE APPROACH Teacher: I see the tics. He jerks his head, makes faces, and flicks his hands. Nurse: What do you do about them? Teacher: What can I do? If he isn’t disrupting the class, I leave him alone. Even when he is throwing spitballs. Nurse: Spitballs! He shouldn’t be allowed to throw spitballs.

Teacher: Oh, I thought that was a part of his problem. Nurse: Well, throwing spitballs has nothing to do with tics.

EFFECTIVE APPROACH Teacher: I see the tics. He jerks his head, makes faces, and flicks his hands.

Nurse: He cannot help the tics that you are seeing. Tic disorders can exhibit a wide range of severity, from mild to severe and from simple to complex. Some complex tics may be difficult to distinguish from habits or rituals. Teacher: What about things like throwing spitballs? When he does things like that, I try to ignore that behavior. Nurse: Sounds like you give him the benefit of the doubt. (Validation) However, throwing a spitball is not a tic behavior. Teacher: What should I do? Nurse: How do you usually handle that type of behavior? (A modification of reflection) Teacher: I’d ask him to stop and sometimes go into the hall. Nurse: Disruptive behavior that is voluntary in a student with a tic disorder should be handled as you would handle any other child. CRITICAL THINKING CHALLENGE 1. Compare the responses of the nurse in these scenarios. What made the difference in the teacher’s responsiveness to the nurse?

When the child’s fear and anxiety around separation become developmentally inappropriate, separation anxi ety disorder is diagnosed. Separation anxiety disorder is the most common childhood anxiety disorder (Patel & Bryant, 2021). Although many children experience some discomfort on separation from their attachment figures, children with separation anxiety disorder suffer great worry or fear when faced with ordinary separations or being away from home, such as when going to school. When separation is about to occur, children often resist by crying or hiding from their parents. When asked, most children with separation anxiety disorder will express worry about harm to or permanent loss of their major attachment figure. Other children may express worry about their own safety. For a discussion of other anxiety disorders, see Chapter 27. A common manifestation of anxiety is school phobia, in which the child refuses to attend school, preferring to stay at home with the primary attachment figure. The term school phobia was coined to distinguish it from tru ancy; whether it is a phobia in the usual sense is a matter of some debate. However, school phobia is a common comorbidity with other disorders such as general anxiety disorder, social phobia, OCD, depression, and conduct disorder. When a comorbid disorder such as depression is identified, it becomes the focus of treatment. In some

cases, school phobia may resolve when the primary disor der is successfully treated (Tekin & Aydin, 2022).

Epidemiology and Etiology Separation anxiety disorder is estimated at 1% to 6% of school-aged children, with symptoms usually emerging before age 10. Insecure attachment, difficult tempera ments, and genetic factors contribute to the development of separation anxiety disorder. Anxiety disorders are often familial, so it appears that both environmental and genetic factors affect the risk for separation anxiety dis order. Risk factors for separation anxiety disorder include family history of anxiety disorders, loss or trauma to an attachment figure, life stresses (e.g., parental divorce), or changes in the child’s environment (e.g., relocation to a new home or school) (Rapee et al., 2023). Family Response to Disorder There is no single family response to a child who is expe riencing separation anxiety. Parenting style, life events, and environmental factors vary from family to family. The family dynamics related to the child’s behavior have to be carefully assessed. In some instances, the family may be undergoing a separation of a significant family

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