RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, …



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.

PROFORMA SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DESSERTATION

|1. |NAME OF THE CANDIDATE AND ADDRESS |Mr.PARASHURAM.H |

|2. |NAME OF THE INSTITUTION |DAYANANDA COLLEGE OF NURSING OF NURSING, BANGALORE-78 |

|3. |COURSE OF STUDY AND SUBJECT |M.Sc .NURSING |

| | |MENTAL HEALTH NURSING |

| | |DISSERTATION PROTOCOL |

|4. |DATE OF ADMISSION TO COURSE |15-07-2012 |

|5. |TITLE OF THE STUDY: |

| | |

| |“A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING SEPARATION ANXIETY DISORDER IN |

| |CHIDREN AMONG PRIMARY SCHOOL TEACHERS IN SELECTED PRIMARY SCHOOLS IN BANGALORE.” |

6. BRIEF RESUME OF THE INTENDED WORK:

INTRODUCTION:

“Children are the wealth of tomorrow, take care of them if you wish to have a strong India, ever ready to meet various challenges.”

— Jawaharlal Nehru

Children are the most important asset for any society. They are said to be the building blocks of the future of any nation. They are the priceless resources. Today’s children are the tomorrow’s citizen and product of the nation.’’ At the same time they are most vulnerable group for any kind of psychiatric disorders such as autism, conduct disorders, separation anxiety disorder and behavioral problems. They require special attention from all the caretakers around.1

Children constitute a large portion of the population in India. It has been a great challenge to the nation to provide health, education and food to the growing children. School age population comprising of 38% of the country, who are dependent, unproductive but has great potential.

Children face anxiety on a daily basis. Anxiety, which provides the motivation for achievement, is a necessary force for survival. The term anxiety is often used interchangeably with the word stress; however they are not the same. Anxiety is the subjective emotional response to that stressor individuals have experienced throughout the ages.

Anxiety can affect any individuals and all the age groups. Anxiety provides the motivation for achievement or it may have detrimental effects on an individual’s quality of life and functioning. Among children, anxiety may entails difficulties at school and in social interactions. Additionally, anxiety disorders are comorbid with other anxiety or affective disorders and can lead to depression, other mental disorders such as substance abuse disorder and more severe anxiety disorders. Furthermore, the decrease in quality of life and functioning, together with the need for treatment, place a burden on society via indirect and direct costs. For example, in 2003, anxiety disorders accounted for 0.5% of the total health care costs in The Netherlands, and costs were estimated at 275.2 million euro’s.2

A mother who is never apart from her young child may be saying to him or her subliminally: "You are only safe when I'm with you.” Separation anxiety is normal part of development, but individual reactions are partly explained by experience, that is, by how frequently children have been left in the care of others. 34

Separation anxiety disorder (SAD) has been recognized as a disorder of childhood since the DSM-III. The central phenomenology of Separation anxiety disorder focuses on a child's reluctance to be separated from major attachment figures because of his/her fear that something awful might happen to the attachment figure. Although there have been several recent reviews of SAD, 2-5 relatively little is known about Separation anxiety disorder's long-term course and its potential to predispose individuals to future psychopathology.4

Interplay of temperament, attachment, and parenting style is believed key to the development of separation anxiety disorder. A parenting style combining lack of affection and maternal care interacting with overprotection and excessive control has been implicated in school refusal. Lack of parental care and intrusive overcontrol may lead to anxious, insecure attachment as a substrate for separation anxiety disorder and related disorders.14

Sound knowledge about separation anxiety disorder is very essential for the caretakers of the children in the family, teachers in schools and other institutions. Teachers will be the primary caretakers in the school children who plays major role in identifying and referring the children with psychological problem, especially separation anxiety disorder.

6.1 NEED FOR THE STUDY:

Prevalence estimates for the separation anxiety disorder average about 4 percent in children and young adults, and it is more common in girls than in boys. Most children grow out of it, but in some instances the symptoms can persist into adulthood (Harvard Medical School, 2007).13 The prevalence rate of separation anxiety disorder drops from 4.1 percent in 7- to 11-year-old children, to 3.9 percent in 12- to 16-year-olds, and 1.3 percent in 14- to 16-year-olds. The mean age of onset for this disorder is 7.5 years.15 This shows that there is intense need for imparting knowledge in primary school teachers who can identify and help in treating the disorder in early stage.

Lifetime prevalence estimates of childhood and adult Separation anxiety disorder are 4.1% and 6.6%, respectively. The 12-month prevalence estimate of adult Separation anxiety disorder is 1.9%. Somewhat more than one-third (36.1%) of respondents classified in the NCS-R as childhood cases persist into adulthood and 11.5% into the 12 months before the interview. Respondents classified as childhood cases represent 22.5% of all those classified as lifetime cases of adult Separation anxiety disorder and 24.8% of those classified as 12-month adult cases, indicating that the majority of the NCS-R respondents classified as both lifetime (77.5%) and 12-month (75.2%) adult cases had first onsets in adulthood.5

A study was conducted on “Separation Anxiety Disorder in Childhood as a Risk Factor for Future Mental Illness” according to this study - Separation anxiety disorder creates a major vulnerability for mental disorders during young adulthood, clinicians should be sensitive to the presence of Separation anxiety disorder, and children and adolescents with Separation anxiety disorder should be provided with treatment. Future research should evaluate whether successful treatment for Separation anxiety disorder and/or the provision of a preventative intervention during childhood/adolescence reduce the risk for future psychopathology. The estimated percentage of adults with PD/PD-Ag who experienced juvenile Separation anxiety disorder have ranged from 18 to 50%. 8

Illness and hospitalization are all too frequent occurrences in the lives of children and their families. Children 1 to 3 years of age average seven to nine illnesses per year, those 4 to 10 years of age average four to six per year, and those over 10 years of age average four per year. Together, a family with two adults and two children averages 21 illnesses a year. Even though most of these illnesses are minor and cause only transient disruptions of everyday life, it is estimated that 2 to 3 percent of all children have illnesses severe enough to affect growth, development, school performance, or social relationships.15

Based on the available review of literature and investigator’s experience, it is also the responsibility of teachers to bring awareness about the risk factors and to prevent separation anxiety disorder in children, especially the adolescent to obscure them as healthy well being of the society. Hence the investigator selected this study aiming at imparting education to the school children through structured teaching programmed.

6.2 REVIEW OF LITERATURE

Review of literature is organized under the following headings

1. Studies related to prevalence of separation anxiety disorder.

2. Studies related to knowledge of separation anxiety disorder

3. Studies related to teacher’s knowledge of separation anxiety disorder

Literature review focusing on prior research related to topic of the study provides a strong foundation to any fresh research activity. Hence a survey of literature is one of the vital parts of many research endeavor.

6.2.1 Studies related to prevalence of separation anxiety disorder

A study conducted by Katherine Shear, Robert Jin, Ayelet Meron Ruscio, and Ronald C. Kessler, Ellen E. Walters, in 2006 on lifetime prevalence estimates of childhood and adult Separation anxiety disorder. The finding of the study revealed that adult Separation anxiety disorder is 1.9%. As childhood cases persist into adulthood and 11.5% into the 12 months before the interview. Respondents classified as childhood cases represent 22.5% of all those classified as lifetime cases of adult Separation anxiety disorder and 24.8% of those classified as 12-month adult cases, indicating that the majority of the NCS-R respondents classified as both lifetime (77.5%) and 12-month (75.2%) adult cases had first onsets in adulthood.5

Kaplan and Sadock says through the textbook of psychiatry that Prevalence estimates for the separation anxiety disorder average about 4 percent in children and young adults, and it is more common in girls than in boys. Most children grow out of it, but in some instances the symptoms can persist into adulthood (Harvard Medical School, 2007).13 The prevalence rate of separation anxiety disorder drops from 4.1 percent in 7- to 11-year-old children, to 3.9 percent in 12- to 16-year-olds, and 1.3 percent in 14- to 16-year-olds. The mean age of onset for this disorder is 7.5 years.15

6.2.2 Studies related to knowledge of separation anxiety disorder

The study called “Teacher Awareness of Anxiety Symptoms in Children” was conducted by Ann E. Layne, Gail A. Bernstein, John S. March in 2006 aimed to determine which anxiety symptoms in children are associated with teacher awareness and whether teacher awareness differs according to student age and gender. The Multidimensional Anxiety Scale for Children (MASC) was completed by 453 second through fifth grade students and teachers nominated the three most anxious students in their classrooms. A multivariate analysis of variance was conducted with MASC scale scores as the dependent variables. The result revealed that children identified by teachers as anxious had significantly higher levels of overall anxiety, physiological anxiety, social anxiety, and separation anxiety.19

According to a study on “Understanding the separation anxiety disorder,” conducted by Carol J. Dashiff , when children are acutely ill and life is threatened, separation anxiety can develop in parents and children. Separation anxiety has been studied through two traditions—as a normative phenomenon and as a disorder. The objective was to analyze and evaluate the literature to derive clinical and research implications. Support was found for the development of interventions beyond the developmental stage of early childhood. The need for a family and school approach was evident.9

A retrospective study named “Separation Anxiety Disorder in Childhood as a Risk Factor for Future Mental illness’ was conducted by Peter M. Lewinsohn, Jill M. Holm-Denoma, Jason W. Small, John R. Seeley, Thomas E. Joiner to ascertain the extent to which childhood separation anxiety disorder confers risk for the development of psychopathology during young adulthood (ages 19–30). Result showed that Separation anxiety disorder was a strong (78.6%) risk factor for the development of mental disorders during young adulthood. The major vulnerabilities were for panic disorder and depression.8

A comparative study has been done regarding Children suffering from separation anxiety disorder show increased HPA axis activity compared to healthy controls. Little is known about the association between Separation anxiety disorder and the hypothalamic-pituitary-adrenocortical (HPA) axis activity. Therefore, this study aimed at investigating this association in children suffering from separation anxiety compared to healthy controls. Result impressed that Compared to healthy controls, children with Separation anxiety disorder showed greatly increased HPA axis activity, as reflected by an increased cortisol secretion throughout the entire period of investigation. This pattern of results suggests that both the anticipation of a separation and a persistent hyperactivity of the HPA axis system leads to an increased cortisol secretion.10

In a study conducted by Won Ju Jeong, Woon Young Kim, Man Gook Moon, Doo Jae Min, Yoon Sook Lee, Jae Hwan Kim, Young Cheol Park in 2012 on “ The effect of ketamine on the separation anxiety and emergence agitation in children undergoing brief ophthalmic surgery under desflurane general anesthesia” concludes that in children undergoing brief ophthalmic surgery with desflurane anesthesia, ketamine 1.0 mg/kg administered before entering the operating room reduced separation anxiety, postoperative pain, and incidence of EA without delay in recovery.

In a study called “Forced choice reaction time paradigm in children with separation anxiety disorder, social phobia, and non-anxious controls” by Tina In-Albon, Kathrin Dubi, Ronald M. Rapee, Silvia Schneider in 2009, a forced choice reaction time paradigm with picture stimuli was used to assess the interpretation bias in anxious children online. The study investigated disorder-specific interpretation bias in 71 children with separation anxiety disorder, 31 children with social phobia, and 42 children without mental disorders, aged 5–13 years. Results indicated that children with Separation anxiety disorder rated ambiguous separation pictures as significantly more unpleasant and more arousing than non-anxious children. However, no support was found that children with Separation anxiety disorder and social phobia interpret ambiguous separation or social pictures in a more negative way than non-anxious children. Furthermore, no group differences were found in reaction times to all picture categories.11

Studies related to teacher’s knowledge of separation anxiety disorder

A investigative study called “Beliefs regarding child anxiety and parenting competence in parents of children with separation anxiety disorder” by Chantal Herren, Tina In-Albon, Silvia Schneider to investigate the specific association between parental beliefs and child separation anxiety. Results indicated that parents of anxious children had significantly higher levels of dysfunctional beliefs than the parents in the HC group. Mothers of children with Separation anxiety disorder showed lower levels of parenting self-efficacy than mothers of children with SoP. They also demonstrated lower parenting self-efficacy and satisfaction compared to mothers of healthy children. Parental dysfunctional beliefs about child anxiety and paternal parenting self-efficacy were significantly positively associated with child anxiety.12

A study named “Preschool teacher attachment, school readiness and risk of learning difficulties” by Elena Commodari summarizes that Attachment is the emotional bond between children and their caregivers (parents, teachers or otherwise). Secure attachment to a preschool teacher may help children to improve their preschool experience. Recent studies suggest that the adverse effect of inadequate preschool experiences can lead to skill deficiencies that mimic the effects of basic cognitive deficits. This study evaluates the relationships among attachment to preschool teachers, school readiness, and the risk for developing learning difficulties in preschoolers using three measures: the School Readiness 4-5 battery, the Precocious Identification of Learning Difficulties, and the Attachment Q Set. This study examined 152 preschoolers. The results showed that attachment to preschool teachers is related to linguistic development level, the psychomotor skills involved in school readiness, and learning difficulty risk.16

A study was conducted by Gail a. Bernstein, Ann e. Layne, Elizabeth a. Egan, and Dana M.Tennison, stating “School-Based Interventions for Anxious Children” to compare the effectiveness of three school-based interventions for anxious children: group cognitive-behavioral therapy (CBT) for children, group CBT for children plus parent training group, and no-treatment control. Clinician-report, child-report, and parent-report measures of child anxiety demonstrated significant benefits of CBT treatments over the no-treatment control group. Effect size was 0.58 for change in composite clinician severity rating, the primary outcome measure, favoring collapsed CBT conditions compared with control. In addition, several instruments showed significantly greater improvement in child anxiety for group CBT plus parent training over group CBT alone.18

A study was conducted in by Anand Sudhan, Arun Pandey, Suresh Pandey, Praveen Srivastava, Kamta Prasad Pandey, and Bhudhendra Kumar Jainon “Effectiveness of using teachers to screen eyes of school-going children in Satna district of Madhya Pradesh, India” to assess the effectiveness of teachers in a vision screening program for children in classes 5th to 12th attending school in two blocks of a district of north central India. Teachers referred 3,822 children (4.91%) with eye defects for further examination by the ophthalmic assistant who confirmed eye defects in 1242 children (1.80% of all screened children). Myopia (n=410, 33.01%), Vitamin A deficiency (n=143, 11.51%) and strabismus (n=134, 10.79%) were the most common eye problems identified by the ophthalmic assistant. Ophthalmic assistants identified 57.97% referrals as false positives and 6.08% children as false negatives from the random sample of normal children. Primary vision screening by teachers has effectively reduced the workload of ophthalmic assistants. High false positive and false negative rates need to be studied further.20

A longitudinal study was conducted by Sasha g. Aschenbrand, philip c. Kendall, alicia webb, Scott m. Safford, ellen flannery-schroeder in 1993 on “Is Childhood Separation Anxiety Disorder a Predictor of Adult Panic Disorder and Agoraphobia?” to examine whether separation anxiety disorder Separation anxiety disorder in childhood is a risk factor for panic disorder and agoraphobia in adulthood. Patients (n = 85) who had completed treatment for Separation anxiety disorder, generalized anxiety disorder, and/or social phobia 7.42 years earlier (on average) were reassessed using structured diagnostic interviews. Subjects with a childhood diagnosis of Separation anxiety disorder did not display a greater risk for developing panic disorder and agoraphobia in young adulthood than those with other childhood anxiety diagnoses. These results argue against the hypothesis that childhood Separation anxiety disorder is a specific risk factor for adult panic disorder and agoraphobia.14

According to a study by Louis P. Hagopian, Keith J. Slifer in 1993 on “Treatment of separation anxiety disorder with graduated exposure and reinforcement targeting school attendance: a controlled case study”, A six-year, nine-month old girl with school avoidance and a variety of other anxiety symptoms was diagnosed with Separation Anxiety Disorder (SAD). Separation anxiety disorder was treated using graduated exposure with positive reinforcement for approximations of independent school attendance. Follow-up indicated that treatment gains were maintained at two- and nine-months post-treatment. Separation anxiety disorder is discussed as a childhood disorder involving fear and avoidance of separation from parents in a variety of situations, one of which may be attending school. The importance of differentiating Separation anxiety disorder from school phobia and other anxiety disorders is discussed.1

d

STATEMENT OF THE PROBLEM:

“A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING SEPARATION ANXIETY DISORDER IN THE CHILDREN AMONG PRIMARY SCHOOL TEACHERS IN SELECTED PRIMARY SCHOOLS IN BANGALORE.”

6.3 OBJECTIVES:

1. To assess the level of knowledge regarding separation anxiety disorder among primary school teachers in the selected primary schools in Bangalore.

2. To evaluate the effectiveness of structured teaching programme regarding separation anxiety disorder among primary school teachers.

3. To find the association between the post test level of knowledge and selected sociodemographic variables.

6.4 HYPOTHESES:

H01 - There is no significant difference between pre test and post test level of knowledge

of primary school teachers in the selected primary schools.

H02 - There is no significant association between the post test level of knowledge and

selected socio-demographic variables.

6.5 ASSUMPTIONS:

1. Structured teaching programme may be an acceptable teaching strategy for

creating awareness on separation anxiety disorder among primary school teachers.

2. Structured teaching programme regarding separation anxiety disorder may

improve the level of knowledge of primary school teachers.

3. Structured teaching program regarding separation anxiety disorder may be helpful

to early identification of the cases.

6.6 OPERATIONAL DEFINITION:

EFFECTIVENESS: Refers to gain in knowledge regarding separation anxiety

disorder among primary school teachers in selected primary schools as manifested by

significant improvement in post-test knowledge score as measured by structured

knowledge questionnaire.

STRUCTURED TEACHING PROGRAMME: Its refers to organized teaching

activity by the investigator to impart knowledge among primary school teachers

regarding separation anxiety disorder which includes meaning, causes, risk

factors, complications and prevention.

KNOWLEDGE: It refers to the ability of primary school teachers in the selected primary schools to give correct responses to the questions regarding separation anxiety disorder.

SEPARATION ANXIETY DISORDER (SAD): The separation anxiety disorder is developmentally inappropriate anxiety sufficient to cause clinically significant distress or impairment when faced with separation from home or major attachment figures.

CHILDREN: It refers to children who are studying in primary school and comes under the age group of 5-13 years in selected primary schools in Bangalore.

6.7 DELIMITATIONS:

1. This study is delimited to children who are in the age group of 5-13 years, at

selected primary schools in Bangalore.

2. Study is delimited for one month period of data collection.

7. MATERIALS AND METHODS

7.1 Source of Data

Primary school teachers at selected primary schools in Bangalore.

7.2 Methods of Data Collection

7.2.1 Type of Study/approach:

Evaluative study.

7.2.2 Research Design

Quasi-experimental, one group pre test, post test design.

7.2.3 Variables

➢ Dependent variable: Knowledge of primary school teachers regarding separation anxiety disorder.

➢ Independent variable: Structured teaching programme regarding separation

anxiety disorder.

7.2.4 Sampling Technique

Simple Random Sampling technique

7.2.5 Sample and Sample Size

60 primary school teachers

7.2.6 Selection Criteria

Inclusion criteria

➢ Teachers working in selected primary schools in Bangalore.

➢ Who are available during the period of data collection

➢ Who can read, understand and respond in English to the structured

questionnaire

Exclusion criteria : Primary school teachers who-

➢ are not willing to participate in the study.

7.2.10 Data collection tool consists of

Section A: Age, education, marital status, working period, income, years of experience, previous knowledge.

Section B: Structured knowledge questionnaire regarding separation anxiety

Disorder. If yes, source of knowledge.

7.2.11 Data Collection Method:

The investigator will explain the purpose of the study after the written consent from the participants and structured questionnaire will be administered followed by administration of a teaching programme and a post test after 7 days of teaching programme.

7.2.12 Plan for statistical analysis:

The data obtained will be analysed in terms of objectives of the study using descriptive and inferential statistics. The plan of data analysis is as follows:

Descriptive statistics:

➢ Frequency and percentage distribution will be used to analyse the socio- demographic data and knowledge scores.

➢ Mean, mean percentage and standard deviation of pre test and post test knowledge scores will be used to assess the knowledge.

Inferential statistics:

➢ Paired t -test to assess the effectiveness of structured teaching programme on knowledge regarding separation anxiety disorder.

➢ “Chi-square” to determine the association between level of post test knowledge regarding separation anxiety disorder and selected socio-demographic variables.

7.3 Does the study require any investigation or intervention to be conducted on patients or other humans or animals? If so, please describe briefly.

Yes, structured teaching programme regarding separation anxiety disorder will be provided to teachers at primary schools and the level of knowledge is assessed by using structured knowledge questionnaire.

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

Ethical clearance will be obtained from concerned authority and the ethical

committee. Written consent will be obtained from the subjects

8. LIST OF REFERENCES:

1. Park K. Park’s text book of preventive and social medicine. 20th ed. Jabalpur: M/s Banarsidas Bhanot; 2009. p. 215-217.

2. Ellin Simon, Susan Maria Bögels, Eur Child Adolesc Psychiatry. 2009 October;  18(10): 625–634. Published online 2009 May 5. doi: 10.1007/s00787-009-0023-x. (PMCID: PMC2744785)

3. Columbia World of Quotations. Retrieved January 02, 2013, from website:

4. Peter M. Lewinsohn, Jill M. Holm-Denoma, Jason W. Small, John R. Seeley, Thomas E. Joiner, Jr.J Am Acad Child Adolesc Psychiatry. Author manuscript; available in PMC 2009 August 26. Published in final edited form as: J Am Acad  Child  Adolesc Psychiatry. 2008 May; 47(5): 548-555. doi: 10.1097/CHI.0b013e31816765e7. (PMCID: PMC2732357)

5. Katherine Shear, MD, Robert Jin, MA , Ayelet Meron Ruscio, PhD and Ronald C. Kessler, PhD, Ellen E. Walters, MS. Prevalence and Correlates of Estimated DSM-IV Child and Adult Separation Anxiety Disorder in the National Comorbidity Survey Replication (NCS-R). Am J Psychiatry. 2006 June ; 163(6): 1074–1083.

6. Census of India. Chapter 3 – Child population in the age group 0-6 years

7. World population of children. U.S. Agency for International Development Bureau for Global Health Office of Population and Reproductive Health.

8. Peter M. Lewinsohn, Jill M. Holm-Denoma, Jason W. Small, John R. Seeley, Thomas E. Joiner, Jr.J Am Acad Child Adolesc Psychiatry. Author manuscript; available in PMC 2009 August 26. Published in final edited form as: J Am Acad Child Adolesc Psychiatry. 2008 May; 47(5): 548-555.  doi: 10.1097/ CHI.0b013e31816765e7 [PMCID: PMC2732357]

9. Carol J. Dashiff .Journal Of Child And Adolescent Psychiatric Nursing

Volume 8, Issue 2, April 1995, Pages: 27–38,

Article first published online : 13 AUG 2007, DOI: 10.1111/j.1744-6171.1995.tb00527.x

10. Serge Brand, Frank H. Wilhelm, Joe Kossowsky, Edith Holsboer-Trachsler, Silvia Schneider .Journal of Psychiatric Research, Volume 45, Issue 4, April 2011, Pages 452-459

11. Tina In-Albon, Kathrin Dubi, Ronald M. Rapee, Silvia Schneider

Behaviour Research and Therapy, Volume 47, Issue 12, December 2009, Pages 1058-1065

12. Chantal Herren, Tina In-Albon, Silvia Schneider . Journal of Behavior Therapy and Experimental Psychiatry, Volume 44, Issue 1, March 2013, Pages 53-60

13. Townsend.M.C. psychiatric mental health nursing concepts of care. 5th edition. Philadelphia; F.A.Davis; 2002. Pages 133-137

14. Sasha g. Aschenbrand, philip c. Kendall, alicia webb, Scott m. Safford, ellen flannery-schroeder .Journal of the american academy of child & adolescent psychiatry, volume 42, issue 12, december 2003, pages 1478-1485

15. Sadock, Benjamin James; Sadock, Virginia Alcott

Kaplan & Sadock's Comprehensive Textbook of Psychiatry (2 Volume Set)

Lippincott Williams & Wilkins Publishers; 7th edition (January 15, 2000)

16. Elena Commodari.Preschool teacher attachment, school readiness and risk of learning difficulties Early Childhood Research Quarterly, Volume 28, Issue 1, 1st Quarter 2013, Pages 123-133

17. Louis P. Hagopian, Keith J. Slifer .Treatment of separation anxiety disorder with graduated exposure and reinforcement targeting school attendance: a controlled case study. Journal of Anxiety Disorders, Volume 7, Issue 3, July–September 1993, Pages 271-280

18. Gail a. Bernstein, Ann e. Layne, Elizabeth a. Egan, and Dana M.Tennison

J Am Acad Child Adolesc Psychiatry. Author manuscript; available in PMC 2008

June 30. Published in final edited form as: J Am Acad Child Adolesc

Psychiatry.  2005 November; 44(11): 1118–1127.doi:10.1097/01. chi.0000177323.

40005.al [PMCID: PMC2442034]

19. Ann E. Layne, Gail A. Bernstein, John S. March

Child Psychiatry Hum Dev. Author manuscript; available in PMC 2009 July 17.

Published in final edited form as: Child Psychiatry Hum Dev. 2006; 36(4): 383–392. doi: 10.1007/s10578-006-0009-6 [PMCID: PMC2712232]

20. Anand Sudhan, Arun Pandey, Suresh Pandey, Praveen Srivastava, Kamta Prasad

Pandey, Bhudhendra Kumar Jain.Indian J Ophthalmol. 2009 Nov-Dec; 57(6): 455-

458. doi: 10.4103/0301-4738.57157. PMCID: PMC2812765

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|9. |SIGNATURE OF THE CANDIDATE | |

| | |In today’s Scenario children are prone to many psychological problems. |

|10. |REMARKS OF THE GUIDE |Since they spend more time I schools, the study will enhance the |

| | |teachers to be aware of separation anxiety disorder. |

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|11.1 |NAME AND DESIGNATION |Mrs.DELIMA.D |

| |OF GUIDE |ASSO.PROFESSOR |

| | |DEPT. OF MENTAL HEALTH NURSING |

| | |DAYANANDA SAGAR COLLEGE OF NURSING, KUMARASWAMY LAYOUT, BANGALORE-78 |

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|11.2. |SIGNATURE | |

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|11.3. |HEAD OF THE DEPARTMENT |Mrs.DELIMA.D |

| | |ASSO.PROFESSOR |

| | |DEPT. OF MENTAL HEALTH NURSING |

| | |DAYANANDA SAGAR COLLEGE OF NURSING, KUMARASWAMY LAYOUT, BANGALORE-78 |

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|11.4. |SIGNATURE | |

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|11.5. |REMARKS OF THE PRINCIPAL | |

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|11.6 |SIGNATURE | |

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