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Chapter: Essentials of Psychiatry: Childhood Disorders: Elimination Disorders and Childhood Anxiety Disorders

Separation Anxiety Disorder

Separation anxiety disorder is typified by developmentally in-appropriate and excessive anxiety concerning separation from home or attachment figures.

Separation Anxiety Disorder




Separation 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 attach-ment figures.


·  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 attachment figure.


The diagnosis of early onset separation anxiety disorder is made when symptoms appear prior to the age of six years.


Natural History and Course


The 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.


Etiology and Pathophysiology


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


Diagnosis and Differential Diagnosis


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:

i)          Avoidance of stimuli provoking specific fearfulness or anxi-ety (e.g., separation).


ii)       Escape from aversive social or evaluative situations (e.g., so-cial phobia).


iii)     Attention-getting behavior (e.g., physical complaints/tantrums).


iv)     Positive 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.

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