Separation Anxiety Disorder
anxiety disorder is typified by developmentally in-appropriate and excessive
anxiety concerning separation from home or attachment figures. This diagnosis
is included within the child and adolescent disorders because, although adults
may have separation problems/symptoms, a diagnosis of separation anxiety
disorder is not made in adulthood. The onset of this dis-order, therefore, must
be prior to the age of 18 years. Symptoms (a minimum of three) must be present
for at least four weeks and cause significant distress or impairment in social
or academic functioning. Excessive and developmentally inappropriate levels of
anxiety are manifested by the following behaviors:
Fears and worry about losing, or about harm
befalling signifi-cant attachment figures.
Recurrent and intense distress when leaving home or
Reluctance or refusal to attend school.
Excessive worry about separation from an attachment
figure through getting lost or kidnapped.
Inability to feel comfortable being alone without
the presence of attachment figures or other adults.
Difficulty in sleeping without being in the
presence of an at-tachment figure.
Frequent anxiety dreams about separation.
Repeated complaints of symptom such as nausea,
vomiting, stomach aches, headaches, prior to threatened separation from an
diagnosis of early onset separation anxiety disorder is made when symptoms
appear prior to the age of six years.
community prevalence of SAD is generally estimated to be around 4% in children
and young adolescents; it decreases in prevalence from childhood through
adolescence. Amongst clini-cally referred subjects (aged 5–18 years) with
anxiety disorders, separation anxiety disorder was found to be the most
frequently occurring disorder, with a lifetime prevalence of 44.7%. The age of
onset has been reported to be 4 to 7 years, with earlier onset being associated
with clinical status and comorbidity (Biederman et al., 1997).Separation anxiety, particularly in younger samples, is found more frequently in girls than
boys: a ratio as high as 2.5 : 1. In a 3- to 4-year prospective study (Last et al., 1996) of subjects with anxiety
disorders, 29% of children had separation anxiety disorder (21% had SAD as
their primary diagnosis) at baseline. On follow-up, 92% of children previously
diagnosed with SAD no longer had symptoms that met full criteria for SAD, although
25% had developed a new disorder, most frequently a depressive disorder.
Finding that 50% of adult panic patients had experienced separation anxiety
during childhood, it has been hy-pothesized that separation anxiety may be a
childhood precursor to adult panic disorder and agoraphobia.
Sensitivity to suffocation cues, important in the
carbon diox-ide (CO2) challenge paradigm in panic disorder and
respiratory response, may differentiate children with anxiety disorder, and
separation anxiety in particular, from children without an anxi-ety disorder.
Inhalation of air containing raised CO2 concentra-tion results in
increased catecholamine release throughout the body and perceived anxiety. This
response appears mediated via the locus coeruleus, a group of
norepinephrine-containing neurons originating in the pons and projecting to all
major brain areas. The locus coeruleus forms part of the reticular activat-ing
system (RAS) and functions to regulate noradrenergic tone and activity.
Hypothalamic and thalamic nuclei also play a role in the perception of and
response to external threats. They act by transmitting arousal information from
the RAS to limbic and cortical areas involved in sensory integration and
perception. The thalamus is thought to have a role in the perception of
anxi-ety, whereas the hypothalamic nuclei mediate the response by the neuroendocrine
system. Urinary cortisol has been shown to be raised (indicative of HPA
overactivity) in infants aged 1 year who demonstrated extreme distress when
separated from their primary attachment figure.
Separation anxiety, when developmentally appropriate,
is seen via attachment theory as an adaptive response that infants use to
enhance proximity to their caregivers. In this, when the infant has adequate
proximity to the caregiver in a given context, attachment behaviors (separation
anxiety symptoms) subside and are replaced by alternate behaviors. On the basis
of their response to various experimental paradigms, infants can be categorized
into having different types of attachment. Although the nosol-ogy of attachment
has varied, the most frequently described type of pathological attachment is
known as “insecure attachment”. Excessive distress on separation evinced by
insecurely attached infants appears to be the earliest manifestation of
separation anx-iety disorder, but this pattern is not specific, in that it can
be the precursor of other types of anxiety (e.g., social phobia/avoidant
disorder, panic disorder) in childhood and adolescence
The assessment strategy will depend upon the
child’s age, symptom profile, the sources of available information and the
purpose of the assessment. As discussed above, separation anxi-ety is normal at
some ages and is maximal around 14 months of age. The most prevalent symptoms
in young children (aged 5–8 years) are worry about losing or about possible
harm to an attachment figure, and reluctance or refusal to go to school.
Children aged 9 to 12 years most frequently reported recurrent excessive
distress when separated from home or attachment figures, whereas adolescents
(aged 13–16 years) had physical symptoms on school days. More symptoms were
reported with decreasing age.
The usual unstructured clinical interview can, in
view of its poor reliability and variable symptom coverage, be supple-mented by
standardized diagnostic interviews such as the Diag-nostic Interview Schedule
for Children (DISC) or the Anxiety Disorder Interview Schedule (ADIS) which
have shown accept-able test–retest reliability and validity. In addition, there
are a large number of self-report questionnaires that can assess chil-dren’s
fears and anxieties, either to detect anxiety disorders in community samples or
to distinguish between different anxiety disorders in clinically referred
children. The most useful of these are the Multidimensional Anxiety Scale for
Children (MASC) (March et al., 1997)
and the Screen for Child Anxiety Related Emotional Disorders (SCARED) (Birmaher
et al., 1997). These have been shown
to have good test–retest reliability, internal consistency and can
differentiate not only anxious children from nonanxious children but also
distinguish specific anxiety disor-ders from each other. Particularly with
younger children, there is value to direct observation of the child either in
determining the diagnosis or in behavioral analysis.
Other issues in assessment of separation anxiety
include: the relative value of information from differing methodologies, how to
integrate information from separate informants, and also the cultural validity
of most measures of anxiety Differential di-agnoses to consider include
generalized anxiety disorder (GAD), where the anxiety is more free-floating,
less situation-specific and occurs independent of separation from the primary
attachment figure. Children with social phobia will display a fear of social situations
where they may be the object of public scrutiny. This anxiety may be
ameliorated by the presence of a familiar person but will not occur exclusively
when the attachment figure is a bsent, as with separation anxiety.
School refusal has long been associated with
separa-tion anxiety disorder, though this relationship holds mainly for younger
children when school nonattendance is most closely linked to fear of
separation, whereas in adolescents fear of school and social-evaluative
situations is more typical. It is important in the assessment of school
nonattendance, a frequent impair-ment associated with SAD, to distinguish
anxiety-related school refusal from conduct disorder–related truancy. Typically
the school-refusing child will stay at home or with parents, whereas the
truanting child will go off with peers. In the presence of school refusal, a
useful approach (Kearney and Silverman, 1999) is to attempt to categorize the
behavior as fulfilling one of the four following functions:
Avoidance of stimuli provoking specific fearfulness
or anxi-ety (e.g., separation).
from aversive social or evaluative situations (e.g., so-cial phobia).
behavior (e.g., physical complaints/tantrums).
tangible reinforcement (e.g., parental collusion
Following a good behavioral and functional
analysis, the most frequently employed clinical approach to the treatment of
separation anxiety and school refusal is behavioral. The principles of
systematic desensitization to feared objects or situations will be employed,
gradually increasing the amount of separation that can be tolerated in a
graduated fashion. Systematic desensitization usually has three components.
First, a response, incompatible with anxiety (relaxation techneiques), is
taught. The second component is the collaborative construction of a hierarchy
of feared situations. These will range from the very mild (producing mild
disquiet) to the most anxiety provoking (avoided at all costs!). It is
important to include a great deal of specificity indescribing these situations
including the duration spent in the feared situation, the degree to which
others are involved, and the distance from home/attachment figure. After
ranking these feared situations, the final component of treatment is the
regular progression of exposure to feared situations whilst employing anxiety
management techniques. It is important that the child is allowed to exercise
some control over the speed with which new settings are experienced. The
avoidance of reinforcement of unwanted behaviors and the promotion of
fear-coping strategies is similarly important.
In the particular example of school refusal
associated with separation anxiety, it is important to encourage an early
return to school so that secondary impairments (academic fail-ure and social
isolation) are minimized. Generally, if the period of absence has been less
than 2 months then return is very often successful.
In older subjects, cognitive approaches may be more
suc-cessful than the primary behavior strategies usually employed with younger
children. Cognitive approaches postulate that the child’s maladaptive thoughts,
beliefs and attitudes (schema) cause or maintain the experience of anxiety.
Treatment consists of identifying negative self-statements (“I can’t ever do
this”) or external beliefs (“If I’m not there my Mom won’t be able to cope”),
and replacing them with more adaptive beliefs.
Pharmacological treatment studies of separation
anxiety similarly have tended to focus on samples with school refusal behavior
and various diagnostic status and/or comorbidity. Early studies used imipramine
or clomipramine with varying success. Considering safety and efficacy, the
SSRIs appear to be the first-line treatment for separation anxiety disorder, but
more studies are needed to confirm preliminary results. Tricy-clic
antidepressants and benzodiazepines may be considered when the child has not
responded to SSRIs or when adverse effects have exceeded benefits. There is
some evidence that treatments can be additive or synergistic. Alternatively,
when combining drug and psychosocial treatments, a lower dose of one or both
may be possible, with a resultant decrease in ex-pense, inconvenience, or
adverse events. Drug effects are often seen sooner than those due to
exposure-based therapy, though it is hoped that the slower to emerge benefits
of therapy may be more long lasting.