Psychiatric Annals

CME Article 

Separation Anxiety Disorder

Nichole Jurbergs, MA; Deborah Roth Ledley, PhD

Abstract

Most children become upset from time to time when they have to separate from their parents or caregivers, particularly when they encounter new situations such as starting school, going to summer camp, or playing at the home of a new friend. Some children, however, consistently react to separation with excessive anxiety and distress and experience a great deal of interference from their anxiety. For these children, a diagnosis of separation anxiety disorder (SAD) might be warranted.

According to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV),1 the essential feature of SAD is “developmentally inappropriate and excessive anxiety concerning separation from the home or from those to whom the individual is attached,” most typically the child's parents or primary caregiver (for ease of writing, we will use “parents” as the primary caregiver throughout this article).2

In response to such separations, or even in anticipation of them, children with SAD typically exhibit excessive distress manifested by crying, repeated complaints of physical symptoms (eg, stomachaches, headaches), avoidance (eg, refusing to go to school, to sleep alone, to be left alone in the home, or to go play at a friend's house), and engagement in safety behaviors (eg, frequent phone calls to or from parents). The primary concern of children with SAD is that something terrible will happen to their parents (eg, they will get in a car accident and die) or that they will get permanently separated from them (eg, by getting lost or kidnapped). A summary of DSM-IV criteria for SAD is included in the Sidebar (see page 730).

Excessive anxiety surrounding separation from home or from a major attachment figure or caretaker. Three or more of the following eight symptoms must be present for a minimum of 4 weeks, and must be present before age 18:

These symptoms must cause significant distress to the child or caretaker, or impairment in social or academic functioning.

Separation anxiety disorder is only diagnosed when pervasive developmental disorder, schizophrenia, and other psychotic disorders are not present. In adolescents and adults, separation anxiety disorder is not diagnosed if the symptoms are better accounted for by panic disorder with agoraphobia.

Early onset should be specified if onset occurs before age 6.

It is important to differentiate SAD from other disorders, particularly other anxiety disorders. To accomplish this, children should be asked what they fear will occur during a separation from significant others. As already noted, children with SAD fear that something will happen to them or to their parents when they are apart, resulting in their never seeing one another again. Children with other anxiety disorders also might fear separation from parents, but their fears are based on different concerns. Some children fear separating from their parents for fear of having a panic attack. They might worry that if they were to have a panic attack without their parents present, no one would help them. In this case, a diagnosis of panic disorder would be more appropriate. Other children worry about being separated from parents because they might have difficulty socially. For example, a child might not want to go play at a friend's house because he or she is afraid of being ridiculed or rejected. This would be better explained as social anxiety disorder.

Separation anxiety disorder also should be differentiated from generalized anxiety disorder (GAD). Children with GAD often worry about the health and safety of their family members, but this does not necessarily prevent them from separating. Furthermore, children with GAD worry about other things in addition to the health and safety of family members, like doing well in school, making…

Most children become upset from time to time when they have to separate from their parents or caregivers, particularly when they encounter new situations such as starting school, going to summer camp, or playing at the home of a new friend. Some children, however, consistently react to separation with excessive anxiety and distress and experience a great deal of interference from their anxiety. For these children, a diagnosis of separation anxiety disorder (SAD) might be warranted.

According to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV),1 the essential feature of SAD is “developmentally inappropriate and excessive anxiety concerning separation from the home or from those to whom the individual is attached,” most typically the child's parents or primary caregiver (for ease of writing, we will use “parents” as the primary caregiver throughout this article).2

In response to such separations, or even in anticipation of them, children with SAD typically exhibit excessive distress manifested by crying, repeated complaints of physical symptoms (eg, stomachaches, headaches), avoidance (eg, refusing to go to school, to sleep alone, to be left alone in the home, or to go play at a friend's house), and engagement in safety behaviors (eg, frequent phone calls to or from parents). The primary concern of children with SAD is that something terrible will happen to their parents (eg, they will get in a car accident and die) or that they will get permanently separated from them (eg, by getting lost or kidnapped). A summary of DSM-IV criteria for SAD is included in the Sidebar (see page 730).

Sidebar.

Summary of DSM-IV Diagnostic Criteria for Separation Anxiety Disorder

  1. Excessive anxiety surrounding separation from home or from a major attachment figure or caretaker. Three or more of the following eight symptoms must be present for a minimum of 4 weeks, and must be present before age 18:

    • Recurrent, excessive distress related to anticipation of separation from home or caretaker.
    • Persistent, excessive worry about possible harm befalling a caretaker or losing a caretaker.
    • Persistent, excessive worry that an unfortunate event will lead to separation from a caretaker.
    • Persistent reluctance or refusal to go to school, or other places without the caretaker, due to fear of separation.
    • Persistent, excessive fear of or reluctance to be at home alone or with adults other than the caretaker.
    • Persistent reluctance or refusal to go to bed alone or to sleep while away from home.
    • Recurrent nightmares regarding separation.
    • Recurrent somatic complaints at times separation occurs or is anticipated, including headaches, stomach aches, and nausea.
  2. These symptoms must cause significant distress to the child or caretaker, or impairment in social or academic functioning.

  3. Separation anxiety disorder is only diagnosed when pervasive developmental disorder, schizophrenia, and other psychotic disorders are not present. In adolescents and adults, separation anxiety disorder is not diagnosed if the symptoms are better accounted for by panic disorder with agoraphobia.

  4. Early onset should be specified if onset occurs before age 6.

Summary of Diagnostic Criteria for Separation Anxiety Disorder

It is important to differentiate SAD from other disorders, particularly other anxiety disorders. To accomplish this, children should be asked what they fear will occur during a separation from significant others. As already noted, children with SAD fear that something will happen to them or to their parents when they are apart, resulting in their never seeing one another again. Children with other anxiety disorders also might fear separation from parents, but their fears are based on different concerns. Some children fear separating from their parents for fear of having a panic attack. They might worry that if they were to have a panic attack without their parents present, no one would help them. In this case, a diagnosis of panic disorder would be more appropriate. Other children worry about being separated from parents because they might have difficulty socially. For example, a child might not want to go play at a friend's house because he or she is afraid of being ridiculed or rejected. This would be better explained as social anxiety disorder.

Separation anxiety disorder also should be differentiated from generalized anxiety disorder (GAD). Children with GAD often worry about the health and safety of their family members, but this does not necessarily prevent them from separating. Furthermore, children with GAD worry about other things in addition to the health and safety of family members, like doing well in school, making friends, and world affairs.

While differential diagnosis is certainly important, clinicians should also be mindful that children diagnosed with SAD often have comorbid psychiatric disorders. In clinical samples, approximately one half of children with SAD are diagnosed with an additional anxiety disorder, most commonly specific phobia or GAD. In fact, one study found that children with primary SAD are more likely to have a comorbid anxiety disorder than children with a primary diagnosis of any other anxiety disorder.3 Depression is also prominent, affecting one-third of children with SAD.

Prevalence, Onset, and Course

The prevalence of SAD typically is cited as between 3.5% and 5.4%.2 However, a much higher percentage of children experience subclinical levels of the disturbance not warranting a diagnosis. Prevalence decreases from childhood to adolescence.1 Several studies have found higher rates of SAD in girls compared with boys,4 although it is generally accepted that no significant gender differences exist.5 It was previously thought that low socioeconomic status was associated with a higher prevalence of SAD. A recent study was unable to find a robust effect of socioeconomic status but identified that paternal absence may increase vulnerability for SAD in girls.6

Onset of SAD can be acute or insidious.2 Acute onset generally follows a significant stressor in the child's environment such as starting school, moving to a new home, or other changes in the family circumstances (eg, divorce). The course of SAD appears to be quite variable. Some children, especially those with acute onset, recover completely with no apparent long-term effects. In fact, for most children, SAD symptoms dissipate while still in early childhood.7 Others, however, experience a more chronic and persistent course. Children experiencing later onset, comorbidity with other psychiatric disorders, and a family history of psychiatric illness are at greater risk for developing anxiety disorders as an adult. Specifically, when SAD persists, the odds of developing the adult equivalent of the disorder8 or panic disorder9 increases. Some researchers argue that SAD is actually an early manifestation of panic disorder, rather than just a risk factor or precursor.10

Etiological Factors

While there has been considerable research on the etiological factors underlying anxiety disorders in children, there is a dearth of research specifically examining children with SAD. The most interesting findings have emerged from studies of the role of attachment styles and parenting in the development and maintenance of SAD. Attachment theory posits that people develop schemas for understanding their social world via their most early interpersonal relationships, namely with their parents or primary caregivers. Furthermore, attachment theory suggests that the quality of this relationship can have a major impact on personality development.11

Attachment theorists have distinguished between secure and insecure attachment relationships.12 Securely attached children have parents who are attentive and responsive, while insecurely attached children have parents who are inconsistent, neglectful, and undependable. Children with secure and insecure attachment relationships differ significantly when they are put into a novel situation without their parents.13 Children who are in secure attachment relationships typically feel comfortable exploring the world on their own, knowing that their parents will come back for them. Children in insecure attachment relationships typically become very upset upon separation from their parents, and even when their parents return, may be very difficult to console. This latter situation is very similar to that of children with SAD when separated from their parents. Attachment theory suggests that parents of insecurely attached children have not been available or responsive consistently and have not taught their children appropriate coping skills to help them feel secure in their absence.12 It is possible the same issues apply to children with SAD. It is important to note, when considering these data, and their application to SAD, that parenting style likely interacts with child temperament. Children who have anxious temperaments can be difficult to parent and, during infancy, parents might become frustrated with their inability to soothe their children. This might contribute to inconsistent or unresponsive parenting. Unfortunately, research on the role of temperament in SAD is lacking.

Two other lines of research support the notion that parents of anxious children might not teach their children coping skills to manage independently of them. First, parents of anxious children have been found to grant less autonomy to their children than parents of nonanxious children.14 This tendency to be overly controlling of children also might communicate to them that they cannot handle challenges on their own. Second, parents of children with SAD have much higher rates of anxiety and mood disorders than parents of children without the disorder.4 Parents who are themselves anxious or depressed might avoid situations in their own lives, modeling fearful behavior to their children. Furthermore, when parents are depressed or avoidant, it is less likely that they will facilitate activities for their children such as playdates or participation in extracurricular activities.

Interestingly, this research on parenting fits well with studies of cognitive style in anxious children. When compared with nonanxious children, those with SAD, social phobia, and GAD experience more negative thought processes, judge ambiguous situations as more dangerous, and have less confidence in their ability to cope with danger.15 Further research is needed on the unique relationships between SAD, attachment, and parenting styles and how attachment and parenting influences the cognitive style of children with SAD.

Assessment of Separation Anxiety Disorder

The American Academy of Child and Adolescent Psychiatry developed practice parameters for the assessment and treatment of children and adolescents with anxiety disorders.16 Important areas to assess when evaluating a child for any anxiety disorder include history of onset and development of symptoms, associated stressors, medical history, family psychiatric history, social history, school history and current functioning, history of trauma, developmental history with special attention to temperament, and mental status. This information may be gathered in the course of a comprehensive, unstructured clinical interview. A structured diagnostic interview tool may also be used. Structured interviews such as the Schedule for Affective Disorders and Schizophrenia for School-age Children,17 the Diagnostic Interview for Children and Adolescents – Revised,18 the Diagnostic Interview Schedule for Children,19 and the Anxiety Disorders Interview Schedule for Children20 establish diagnosis based on an established classification system (eg, DSM-IV).

While these interviews can be time-consuming, they are quite reliable and ensure that clinicians inquire about all of the possible areas (eg, mood disorders, anxiety disorders) that can be causing difficulties for patients. During the course of the clinical interview, and throughout the assessment, a clinician should be observing the behavior of the child or adolescent. Fidgeting, fingernail biting, avoiding eye contact, and speaking softly, all behaviors that might suggest anxiety, should be noted.21

Other behaviors to look for include school refusal, bedtime problems, and certain somatic complaints. School refusal is reported in about 75% of children with SAD.22 Common bedtime problems seen in children with SAD include recurring nightmares with separation themes, reluctance to go to bed, refusal to go to bed without a parent present, and repeatedly going to the parent's room during the night. A child with SAD might even sleep on the floor outside a parent's room if they are not permitted to sleep with them. Somatic complaints common in children with SAD include stomach-aches, headaches, nausea, and vomiting. Often, young children experience heart palpitations, dizziness, and feeling faint when separation occurs or is anticipated. Children with SAD frequently present to pediatricians with abdominal pain and nausea on school days, having used physical complaints to avoid the separation of attending school.2 Finally, a very good “litmus test” of SAD is the willingness of the child to separate from the parent during the assessment.

A number of standardized rating scales have also been developed that can be used in concert with a clinical interview. Some assessment instruments, such as Achenbach's Child Behavior Checklist23 and the Behavioral Assessment System for Children,24 are designed to be broad-band measures of childhood and adolescent psychopathology. Parent, teacher, and self-report versions of these questionnaires are available. They are useful when screening for the presence of psychiatric symptoms and possible comorbidities of disorders. Narrowband instruments have been constructed to assess the specific symptoms of anxiety as well. These self-report inventories are economical both financially and with respect to time, making them the most widely used method for assessing childhood anxiety. However, they possess a number of limitations as well, including failure to capture the fears of each individual child and failure to reflect the child's internal state. These limitations aside, self-report measures are extremely useful. Several of the most common such instruments are the Revised Children's Manifest Anxiety Scale,25 the Multidimensional Assessment Scale for Children,26 the Fear Survey Schedule for Children – Revised,27 and the State-Trait Anxiety Inventory for Children.28

When evaluating for the presence of SAD, as with any childhood psychiatric disorder, information should be gathered from multiple sources. A parent or caretaker can provide objective data regarding the child's behavior. Due to the subjective nature of anxiety symptoms, it is essential to include measures that assess the symptoms from the child's perspective.21 It is often appropriate and helpful to interview or obtain rating scales from a child's teacher as well, offering objective data on classroom behavior. This is especially useful when the child's school performance is affected by anxiety.

A medical examination should also be conducted with the intent to rule out conditions that mimic the symptoms of anxiety disorders such as hypoglycemic episodes, hyperthyroidism, cardiac arrhythmias, caffeinism, pheochromocytoma, seizure disorder, migraine, central nervous system disorders, and medication reactions.16

Treatment

Treatment of SAD often involves a multimodal approach that may include psychoeducation of the patient and family, school consultation and intervention, pediatrician consultation and pharmacotherapy, and cognitive-behavior therapy (CBT). Research has repeatedly demonstrated the efficacy of CBT for children with SAD, supporting it as the best-proven treatment.22 Pharmacotherapy should be used in conjunction with CBT only when the child's symptoms have not responded to CBT interventions alone.

Treatment for SAD is time-limited (usually fewer than 20 sessions), present-focused, and problem-focused. Rather than delving into the origins of the SAD, focus is placed on changing current behaviors and improving functioning. Typically, the first few sessions of treatment focus on psychoeducation of the parent and child, as well as treatment planning. Psychoeducation involves teaching the parent and child about the factors that maintain SAD over time, and what will be done during treatment to try to ameliorate the problem. Specifically, by avoiding situations, children never give themselves a chance to learn that the bad things that they fear are unlikely to occur. In treatment, the child, parents, and therapist work together to help the child confront these feared situations gradually through specific behavioral exercises called exposures. The goal of exposures is to help children form new beliefs about their feared situations and about their abilities to cope.

It is essential to tailor treatment to the individual child. The best way to learn about how SAD affects a child's life is to have him or her engage in self-monitoring. This involves writing down situations that trigger anxiety, rating how much anxiety each situation provokes (usually on a 0 to 10 scale), and noting accompanying physical (eg, racing heart, sweaty hands), cognitive (eg, “I'm scared Mom's not going to come back”), and behavioral symptoms (eg, cry until Mom lets me come home with her). Early in treatment, self-monitoring helps the therapist and child learn about the child's SAD and design a treatment program to target the situations that are problematic. Later in treatment, self-monitoring serves as a record of how children use their newly learned skills to manage anxiety-provoking situations most effectively.

Self-monitoring can be difficult for younger children to do on their own, so parents can help children with this task. Older children can manage self-monitoring on their own, and the therapist can facilitate compliance by making this task fun. Children can do their self-monitoring on the computer, can draw pictures to accompany their self-monitoring, or can use a nice notebook they bought specifically for their therapy.

Early in treatment, a hierarchy of feared situations is created to serve as a road map for treatment. This hierarchy is essentially a list of events and situations the child is afraid of, in order from least to most feared. It should be created with a great deal of detail so that moving through each “step” on the hierarchy very gradually exposes the child to situations that involve separation. For example, rather than having “being home alone” as one step, the hierarchy might include “being home with a babysitter while mom is at work,” “being home alone during the day while mom is at the store for an hour,” and “being home alone at night while mom is out to dinner.”

Each child's hierarchy is different because the situations and the order in which they are placed are selected by the individual child according to his or her own idiosyncratic concerns. It is important that hierarchies take into account the child's age. For younger children, many exposures will allow for the presence of other adults besides the child's parents (eg, going to play at a friend's house with his or her parents at home; staying at home with a babysitter when mom and dad go out), while for older children, exposures might involve being alone (eg, staying home alone) or doing things with friends without adults present (eg, going to a movie with a friend). Parents should be involved in the process of building a hierarchy to provide information about specific situations in which the child reacts anxiously and to inform the clinician of exposures that are important to the functioning of the child and the family (eg, does the parent want or expect their child to be able to stay home alone?).

Once children and parents have a grasp of the CBT model for understanding and treating SAD, and once a hierarchy has been developed, the most important component of treatment can begin — exposure to the feared situations. The graduated exposures are designed to extinguish the child's fear response to the situation via two specific changes. First, children experience habituation of anxiety; that is, they become less anxious the longer they stay in situations and with each repeated exposure to the same situation. They learn that their anxiety will go away without having to avoid or leave the situation. Second, children come to learn that the outcomes that they fear are unlikely to occur. For example, if a child is nervous that his mom will get in a car accident on the way home from being out in the evenings, seeing her repeatedly come home safely serves to disconfirm these beliefs. Concurrent with exposures, it is important to teach children effective coping skills. For example, if this child is home alone, he will probably fare better if he gets busy with something (eg, his homework, watching a sporting event on TV, playing on the computer), rather than calling his mother repeatedly through the evening to make sure she is okay. While these “coping strategies” could be seen as distraction (which could block the process of habituation), it can be more helpful to conceptualize them as replacements for safety behaviors (such as repeatedly calling mom to check on her) that only serve to maintain anxiety over time.

The process of exposures typically begins with the first situation on the hierarchy. For many children this first step may be coming into the therapy room alone while a parent waits in the waiting room. In fact, for some children, even this step might have to be broken down into smaller steps such as “enter therapy room while mom stands right outside door,” “stay in therapy room without mom for five minutes,” and so on until the child is able to remain comfortably with the therapist and without the parent present for the full session. Homework assignments are given at each session and are usually planned exposures in the home or other natural environment. For a child who fears being home alone, a typical week of homework assignments might include staying home alone while mom leaves the house for 10 minutes, 30 minutes, and then for a whole hour. Parental involvement is particularly essential in conducting successful homework exposures. The child, parent, and therapist must act as a team in planning and agreeing upon the assignments. The parents must understand the importance of their role in the exposures. In the example given above, the parent must arrive home no later than the specified time. Failure to follow through with the plan reinforces the child's separation fears and anxious responses. Only when a child learns that he can rely on his caretakers to provide for his needs will he be able to separate from them without fear.

It is essential that the child's “bravery” during exposures be reinforced. The therapist and parents can play a significant role here by praising children for their bravery, but it is also important that children give themselves credit for being brave. Reflecting on these acts of bravery can be helpful when confronting feared situations further up the hierarchy. For example, one of our patients spent her summer doing many “brave” acts, like playing at friends' houses, meeting new friends on a family trip abroad, and going on some brief outings with her therapist during sessions. These exposures benefited her greatly when she began school in the fall. She and her therapist had made a special bracelet with beads that spelled out “bravery” that she could look at when she felt nervous riding the bus to school and going to her new classroom. She also found it very helpful to think about the brave things she had accomplished over the summer when she felt nervous at her new school.

In addition to praise, rewards of a more material nature can also be used to help children comply with in-session and homework exposures. Rewards should be contracted between the parent and child during the weekly sessions, with the help of the therapist. They should be clearly tied to engaging in a specific behavior (eg, the child gets a new box of crayons for riding the bus to school), or to engaging in a behavior for a specific period of time (eg, the child gets a pizza dinner if he sleeps alone in his room every night for a week). Rewards should be contingent on engaging in a behavior, not on whether or not the child reacts with anxiety.

Rewards may include special privileges, stickers, candy, or other small tangibles. A sticker chart may also be implemented in which a child earns a sticker for successfully completing each exposure and then uses the accumulated stickers to “buy” larger gifts such as toys or special outings. It can also be very beneficial to reward the child's exposures with special activities that facilitate parental interaction. For example, after going to a playdate at a friend's house, the child might be rewarded with a special pizza dinner out with his mom and dad. Such rewards not only behaviorally reinforce the child's bravery, but also encourage the development of trust and security.12 That is, when the parent provides the contracted reward, the child begins to trust that the parent will follow through on promises and will be responsive to the child in a consistent way.

At the end of treatment, it is important to review with children what they have accomplished. It can be helpful to re-rate the original hierarchy — it can be very rewarding for children to see that situations that elicited anxiety ratings of 10 at the beginning of treatment bring on little if any anxiety at the end of treatment.

It is also essential at the end of treatment to discuss with children how they can maintain their gains once treatment is over. It is likely that children will encounter new situations that bring up their separation-related concerns, like attending overnight camp or beginning a new school. The therapist and the child should discuss strategies that were helpful during treatment and compile a “reminder list” that the child and parent can refer to in new situations. For example, the child might write: “Situations are never as scary as I think they are going to be”; “Mom always comes back when she says she will”; and “As soon as I get busy with other things, I forget to feel sad about Mom leaving.” When new situations come up, parents can help children review this sheet and encourage them to think about these things as they confront new situations. Another helpful tool is to present children with hypothetical situations and ask them how they would help another child deal with their anxieties. Children enjoy this opportunity to “be the therapist” and show off all the knowledge that they have gained in treatment.

Pharmacotherapy

As noted above, only when CBT alone does not decrease the symptoms of SAD should a trial of pharmacotherapy be considered. Selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and benzodiazepines have all been used to treat a number of anxiety disorders in children, including SAD,16 but no medications have specific indications for SAD. Benzodiazepines, although usually tolerated with minimal adverse side effects, are only recommended for short-term use due to the potential for tolerance and dependence.16 When benzodiazepines are prescribed concurrent with CBT, it is important that the child is not given them in response to anxiety experienced during an exposure since the anxiolytic properties of these drugs will block the process of habituation.

It is essential during exposures for children to experience anxiety and then to see that their anxiety decreases as they remain in a situation, without reliance on medication. Tricyclic antidepressants, most commonly imipramine, have been used for decades to treat school refusal, a common symptom of children with SAD.29 In spite of a number a studies illustrating the efficacy of TCAs, SSRIs are currently the first choice drug treatment for SAD.22 In addition to being generally better tolerated than TCAs, SSRIs have the added benefits of safety in overdose and minimal clinical cardiovascular effects.29 Recently, fluoxetine30 and fluvoxamine31 have been recognized for their low side-effect profiles and success in treating children and adolescents with a variety of anxiety disorders.

In October 2004, the Food and Drug Administration issued a warning about the increased risk of suicidal thoughts and behavior in children and adolescents being treated with antidepressant medications (specifically, the SSRIs and “atypical” antidepressants).32 This warning does not prohibit the use of antidepressants in children and adolescents but does require more careful monitoring of children and adolescents who are taking them. Practitioners prescribing these medications must consider risks and benefits of using antidepressants with each individual patient and must be responsive to the fact that some parents will now be hesitant about their children taking them. Where the potential benefits do not seem to outweigh the potential costs, or where parents refuse pharmacological treatment, CBT is an excellent option.

Summary

SAD is a disorder that can cause a great deal of distress and impairment. Children with the disorder often miss school, as well as many other important social opportunities such as playing with friends and participating in extracurricular activities. It is quite likely that, if untreated, SAD can lead to numerous negative psychosocial outcomes. Luckily, effective treatments for SAD are available, including CBT and SSRI pharmacotherapy.

References

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Publishing; 1994.
  2. Black B. Separation anxiety disorder and panic disorder. In: March JS, ed. Anxiety Disorders in Children and Adolescents. New York, NY: The Guilford Press; 1995:212–234.
  3. Verduin TL, Kendall PC. Differential occurrence of comorbidity within childhood anxiety disorders. J Clin Child Adolesc Psychol. 2003; 32(2):290–295. doi:10.1207/S15374424JCCP3202_15 [CrossRef]12679288
  4. Last CG, Francis G, Hersen M, Kazdin AE, Strauss CC. Separation anxiety and school phobia: a comparison using DSM-III criteria. Am J Psychiatry. 1987;144(5):653–657. doi:10.1176/ajp.144.5.653 [CrossRef]3578577
  5. Last CG, Perrin S, Hersen M, Kazdin AE. DSM-III-R anxiety disorders in children: sociodemographic and clinical characteristics. J Am Acad Child Adolesc Psychiatry. 1992; 31(6):1070–1076. doi:10.1097/00004583-199211000-00012 [CrossRef]1429407
  6. Cronk NJ, Slutske WS, Madden PA, Bucholz KK, Heath AC. Risk for separation anxiety disorder among girls: Paternal absence, socioeconomic disadvantage, and genetic vulnerability. J Abnorm Psychol. 2004;113(2):237–247. doi:10.1037/0021-843X.113.2.237 [CrossRef]15122944
  7. Kearney CA, Sims KE, Pursell CR, Tillotson CA. Separation anxiety disorder in young children: A longitudinal and family analysis. J Clin Child Adolesc Psychol. 2003;32(4):593–596. doi:10.1207/S15374424JCCP3204_12 [CrossRef]
  8. Silove D, Manicavasagar V, Drobny J. Associations between juvenile and adult forms of separation anxiety disorder: a study of adult volunteers with histories of school refusal. J Nerv Ment Dis. 2002;190(6):413–414. doi:10.1097/00005053-200206000-00013 [CrossRef]12080215
  9. Casat CD. Childhood anxiety disorders: a review of the possible relationship to adult panic disorder and agoraphobia. J Anxiety Disord. 1988;2(1):51–60. doi:10.1016/0887-6185(88)90013-8 [CrossRef]
  10. Albano AM, Chorpita BF, Barlow DH. Childhood anxiety disorders. In: Mash EJ, Barkley RA, eds. Child Psychopathology. 2nd ed. New York, NY: Guilford Press; 2003:279–329.
  11. Bowlby J. Attachment and loss: retrospect and prospect. Am J Orthopsychiatry. 1982;52(4): 664–678. doi:10.1111/j.1939-0025.1982.tb01456.x [CrossRef]7148988
  12. Weems CF, Carrion VG. The treatment of separation anxiety disorder employing attachment theory and cognitive behavior therapy techniques. Clinical Case Studies. 2003;2(3): 188–198. doi:10.1177/1534650103002003002 [CrossRef]
  13. Ainsworth MDS, Blehar MC, Waters E, Wall S. Patterns of Attachment: A Psychological Study of the Strange Situation. Hillsdale, NJ: Erlbaum; 1978.
  14. Silverman WK, Niederhauser D. Separation anxiety disorder. In: Morris TL, March JS, eds. Anxiety Disorders in Children and Adolescents. 2nd ed. New York, NY: The Guilford Press, 2004:164–188.
  15. Bogels SM, Zigterman D. Dysfunctional cognitions in children with social phobia, separation anxiety disorder, and generalized anxiety disorder. J Abnorm Child Psychol. 2000; 28(2):205–211. doi:10.1023/A:1005179032470 [CrossRef]10834771
  16. King RA. Practice parameters for the psychiatric assessment of children and adolescents. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 1997;36(10 Suppl):4S–20S. doi:10.1097/00004583-199710001-00002 [CrossRef]
  17. Puig-Antich J, Chambers W. The Schedule for Affective Disorders and Schizophrenia for School-age Children (K-SADS). Pittsburgh, PA: Western Psychiatric Institute and Clinic; 1978.
  18. Herjanic B, Reich W. Development of a structured psychiatric interview for children: agreement between child and parent on individual symptoms. J Abnorm Child Psychol. 1982;10(3):307–324. doi:10.1007/BF00912324 [CrossRef]7175040
  19. Costello AJ, Edelbrock C, Kalas R, Kessler MD, Karic SN. The NIMH Diagnostic Interview Schedule for Children (DISC). Unpublished interview schedule. Pittsburgh, PA: University of Pittsburgh Department of Psychiatry; 1982.
  20. Silverman WK, Albano AM. Anxiety Disorders Interview Schedule for Children (DSMIV). San Antonio, TX: Psychological Corporation; 1997.
  21. Kendall PC, Chu BC, Pimentel SS, Choudhury M. Treating anxiety disorders in youth. In: Kendall PC, ed. Child and Adolescent Therapy: Cognitive-behavioral Procedures. 2nd ed. New York, NY: The Guilford Press; 2000:235–287.
  22. Masi G, Mucci M, Millepiedi S. Separation anxiety disorder in children and adolescents: epidemiology, diagnosis, and management. CNS Drugs. 2001;15(2):93–104. doi:10.2165/00023210-200115020-00002 [CrossRef]11460893
  23. Achenbach TM. Manual for the Child Behavior Checklist/4–18 and 1991 Profile. Burlington, VT: University of Vermont Department of Psychiatry; 1991.
  24. Reynolds CR, Kamphaus RW. Behavioral Assessment System for Children. Circle Pines, MN: American Guidance Services; 1998.
  25. Reynolds CR, Richmond BO. What I think and feel: a revised measure of children's manifest anxiety. J Abnorm Child Psychol. 1978; 6(2):271–280. doi:10.1007/BF00919131 [CrossRef]670592
  26. March JS, Parker JD, Sullivan K, Stallings P, Conners CK. The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity. J Am Acad Child Adolesc Psychiatry. 1997;36(4):554–565. doi:10.1097/00004583-199704000-00019 [CrossRef]9100431
  27. Ollendick TH. Reliability and validity of the Revised Fear Survey Schedule for Children (FSSC-R). Behav Res Ther. 1983;21(6): 685–692. doi:10.1016/0005-7967(83)90087-6 [CrossRef]6661153
  28. Spielberger C. Preliminary Manual for the State-Trait Anxiety Inventory for Children (“How I Feel Questionnaire”). Palo Alto, CA: Consulting Psychologists Press; 1973.
  29. Kutcher S, Reiter S, Gardner D. Pharmacotherapy: approaches and applications. In: March JS, ed. Anxiety Disorders in Children and Adolescents. New York, NY: The Guilford Press; 1995:341–385.
  30. Birmaher B, Axelson DA, Monk K, et al. Fluoxetine for the treatment of childhood anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2003;42(4):415–423. doi:10.1097/01.CHI.0000037049.04952.9F [CrossRef]12649628
  31. Fluvoxamine for the treatment of anxiety disorders in children and adolescents. The Research Unit on Pediatric Psychopharmacology Anxiety Study Group. N Engl J Med. 2001;344(17):1279–1285. doi:10.1056/NEJM200104263441703 [CrossRef]11323729
  32. FDA launches a multi-pronged strategy to strengthen safeguards for children treated with antidepressant medications. October15, 2004. Food and Drug Administration Web site. Available at: http://www.fda.gov/bbs/topics/news/2004/NEW01124.html. Accessed January 3, 2005.

Educational Objectives

  1. Describe the diagnosis of separation anxiety disorder (SAD).

  2. Identify possible etiological factors for SAD.

  3. Discuss strategies for assessment and treatment of SAD.

Sidebar.

Summary of DSM-IV Diagnostic Criteria for Separation Anxiety Disorder

  1. Excessive anxiety surrounding separation from home or from a major attachment figure or caretaker. Three or more of the following eight symptoms must be present for a minimum of 4 weeks, and must be present before age 18:

    • Recurrent, excessive distress related to anticipation of separation from home or caretaker.
    • Persistent, excessive worry about possible harm befalling a caretaker or losing a caretaker.
    • Persistent, excessive worry that an unfortunate event will lead to separation from a caretaker.
    • Persistent reluctance or refusal to go to school, or other places without the caretaker, due to fear of separation.
    • Persistent, excessive fear of or reluctance to be at home alone or with adults other than the caretaker.
    • Persistent reluctance or refusal to go to bed alone or to sleep while away from home.
    • Recurrent nightmares regarding separation.
    • Recurrent somatic complaints at times separation occurs or is anticipated, including headaches, stomach aches, and nausea.
  2. These symptoms must cause significant distress to the child or caretaker, or impairment in social or academic functioning.

  3. Separation anxiety disorder is only diagnosed when pervasive developmental disorder, schizophrenia, and other psychotic disorders are not present. In adolescents and adults, separation anxiety disorder is not diagnosed if the symptoms are better accounted for by panic disorder with agoraphobia.

  4. Early onset should be specified if onset occurs before age 6.

Summary of Diagnostic Criteria for Separation Anxiety Disorder

Authors

Ms. Jurbergs is a psychology intern at Mailman Center for Child Development, University of Miami School of Medicine, Miami, FL. Dr. Ledley is assistant professor of psychology in psychiatry, University of Pennsylvania, Philadelphia, PA.

Address reprint requests to: Deborah Roth Ledley, PhD, Center for the Treatment and Study of Anxiety, University of Pennsylvania School of Medicine, 3535 Market St., 6th Floor, Philadelphia, PA 19104.

The authors have no industry relationships to disclose.

10.3928/00485713-20050901-05

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