SEPARATION

ANXIETY
 ATTACHED FIGURE + CHILD

SEPARATED

ATTACHED
CHILD
FIGURE
MINIMAL 4 WEEKS
LESS THAN 18YRS
PHYSICAL SYMPTOMS

SEPARATION
ANXIETY
DISORDER (SAD)
DEFINITION
Separation anxiety is a fairly common
anxiety disorder consisting of excessive
anxiety beyond that expected for the
child's developmental level related to
separation or impending separation from
the attachment figure (eg, primary
caretaker, close family member) occurring
in children younger than 18 years and
lasting for at least 4 weeks.
 Features include clinically significant (ie,
severe distress or impairment of
function) symptoms of anxiety,
unrealistic worries about the safety of
loved ones, reluctance to fall asleep
without being near the primary
attachment figure, excessive distress
(eg, tantrums) when separation is
imminent, nightmares with separation-
related themes, and homesickness (ie,
desire to return home or make contact
with the caregiver when the child is
separated)
 Physical/somatic symptoms (especially
frequent in older children and
adolescents), such as dizziness,
lightheadedness, nausea,
stomachache, cramps, vomiting, muscle
aches, or palpitations, may be present
and problematic, causing the child and
family to seek medical treatment
because of impaired ability to attend
school or meet social responsibilities
Pathophysiology
Separation anxiety is developmentally
normal in infants and toddlers until
approximately age 3-4 years, when mild
distress and clinging behavior occur when
children are separated from their primary
caregivers or attachment figures (eg,
being left in a daycare setting)
 Research results regarding hormonal
influences during pregnancy and the neonatal
period suggest that maternal endocrine
activation during pregnancy (eg, exposure to
adrenocorticotropic hormone [ACTH],
dexamethasone, or conditions that cause
their release) and/or early separation or loss
(eg, the neonate not being raised by the
original primary caregiver) may result in lower
cortisol levels overall and may correlate later
in development with clinically significant
symptoms of anxiety, learned helplessness,
and depression.
 Some children may be more vulnerable
to separation anxiety based on their
temperament (ie, level of anxiety
dealing with new situations) or based on
environmental stresses such as the
death of a close relative or an
interactive pattern with an over-
protective, needy, or depressed parent
 . Studies of children who in first grade
present with significant symptoms of
anxiety (enough to cause clinically
significant impairment in social and
academic functioning) reflect a
correlation with significant impairment in
reading and math achievement 5-6
years later
 Frequency:
In the US: Prevalence ranges from 1.3%
for teenagers aged 14-16 years to 4.1-
4.7% for children aged 7-11 years. In 1987,
Burke et al reported that 5% of school-
aged children are identified as school
refusers.
Internationally: In 1990, Bowen et al
reported a 2.4% overall prevalence rate.
 Mortality/Morbidity:
Mortality generally results from associated major
depression that may lead to suicide.
Long-term follow-up studies of children
successfully treated for school refusal
because of separation anxiety show some
children with continued impairment of social
functioning (ie, social and affective
constriction) despite having returned to
school; this may reflect the long-term
impairment and morbidity in this disorder.
 Sex: Prevalence is approximately equal
between males and females.
Age: Mean onset of separation anxiety
disorder is at age 7.5 years. Mean onset
of school refusal is at age 10.3 years.
Separation anxiety disorder is most
frequent among younger children. One
study lists prevalence rates for children
aged 7-11 years at 4.1%; the same study
lists prevalence rates for children aged 12-
14 years at 3.9% and a prevalence rate of
1.3% for adolescents aged 14-16 years.
 Separation anxiety disorder manifests
slightly differently in different age
groups. Children younger than 8 years
tend to present with unrealistic worry
about harm to their parents or
attachment figures and school refusal.
Children aged 9-12 years tend to
present with excessive distress at times
of separation (eg, sleepaway camp,
overnight school trips).
 Adolescents aged 12-16 years more
commonly present with school refusal
and somatic problems involving
autonomic symptoms, such as
headaches, dizziness, lightheadedness,
sweatiness, or GI or musculoskeletal
symptoms (eg, stomachache, nausea,
cramps, vomiting, muscle or body aches
such as back pain or muscle tension).
CLINICAL
History:
Screen for features of depression (eg,
anhedonia, insomnia, feelings of
worthlessness) and ask the child directly
about symptoms. The onset and development
of symptoms as well as their context helps to
establish the diagnosis of anxiety disorder.
Noting whether anxiety is stimulus-specific,
spontaneous, or anticipatory; if the symptoms
result in avoidant behavior (ie, degree of
constriction of daily life) that is clinically
significant and disabling; and whether social
and familial reinforcers of symptoms exist is
helpful.
 Pertinent educational, developmental, and
family or social history should be obtained,
including any family history of anxiety
disorders and history of separations and
losses, school attendance, academic
functioning, presence of environmental
stressors, and degree of involvement with
peer group and social competence
 when separated or faced with threatened
separation from the primary attachment figure,
along with severe distress and impairment in
functioning. Severe distress and impairment in
functioning may be indicated by the following
signs:
o Reluctance to fall asleep without being near the
primary attachment figure
o Excessive distress (eg, tantrums) when separation is
imminent
o Nightmares about separation-related themes
o Frequent physical or somatic symptoms such
as abdominal pain and palpitations
o Homesickness (ie, a desire to return home or
make contact with the primary caregiver when
separated)
 The family frequently reinforces separation
anxiety symptoms. For example, when the
family experiences a major life stress or
illness and the child expresses mild refusal to
leave the primary caregiver (who may be
anxious, distressed, or depressed), the child
is not firmly encouraged to appropriately
separate and instead is rewarded either
overtly or covertly not to separate (ie, when
the child who refuses to leave is given extra
attention or when the child who refuses to
attend school is excused by the parent). In
these instances, the parent does not clearly
give the child the task of developing
strategies to adapt to the separation.
 Separation anxiety is often the precursor to
school refusal, which occurs in approximately
three fourths of children who present with
separation anxiety disorder.
Boys and girls do not differ significantly in
symptom presentation.
In general, younger children may be referred
more often because older children usually
present with somatic symptoms, which may not
be as clearly correlated with situations of
imminent or actual separation from attachment
figures.
 Physical:
Generally, somatic symptoms, such as
palpitations or abdominal pain, have no clear
physical origin. However, a careful physical
examination with appropriate blood work is
recommended to rule out physical causes,
including occult serologic streptococcal infection;
hyperthyroidism; hypothyroidism; mitral valve
prolapse; asthma; or GI infection, inflammation,
bleeding, or ulceration.
 When approaching the child and family,
reassure both the child and family that
somatic symptoms are indicators of a
problem that is serious and requires
attention. Psychological interventions
should proceed simultaneously with
medical evaluations.
 To help prevent secondary gain, encourage the
child and family to live as normal a life as
possible (despite the symptoms) to prevent
worsening impairment of functioning. This
includes returning to school immediately if
school refusal is an issue.
To help prevent secondary complications, do not
be overzealous in the workup for a physical
etiology of the somatic problems; however, do
be prudent.
 Lab Studies:
Consider the following tests to rule out
possible conditions only when clinically
pertinent and age relevant.
o Triiodothyronine (T3), thyroxine (T4), thyroid-
stimulating hormone (TSH) - To rule out
thyroid abnormalities
o Two-hour postprandial glucose - To rule out
type I or type II diabetes mellitus
o Titers (especially in history of fever, rash, or sore
throat with incomplete or no treatment [with
antibiotics] and history of acute change in
personality or anxiety or obsessive features) - For
antistreptococcal antibodies (ASO titer), Babesia
(to rule out babesiosis), Lyme disease, and
rickettsial illness (eg, Rocky Mountain spotted
fever)
o Blood level of lead and other heavy metals such
as mercury - To rule out lead or heavy metal
poisoning (abdominal pain)
o CBC count, hematocrit (Hct) level, hemoglobin
(Hgb) concentration - To rule out the presence of
anemia, for example, as a cause of abdominal
pain
 o Drug screen of urine for drugs of abuse -
To rule out stimulant or steroid abuse
Imaging Studies:
Ifother information suggests brain tumor or
seizure disorder, perform appropriate
imaging studies (eg, MRI, CT scanning,
positron emission tomography [PET]
scanning).
Obtain an echocardiogram with functional
examination to rule out mitral valve
prolapse or other structural cardiac
abnormalities (eg, regurgitation).
GENERAL VIEW
DSM-IV
INAPPROPRIATE & EXCESSIVE ANXIETY
WHEN SEPARATED FROM MOST ATTACHED
FIGURE
AT LEAST 4 WEEKS
BEFORE 18 YRS
PHYSICAL SYMPTOMS
ONSET PRESCHOOL (3-4%)
MOST COMMON 7-8 YRS OLD
BOYS = GIRLS
 ETIOLOGY

BIOPSYCHOSOCIAL LEARNING GENETIC

FACTORS FACTORS FACTORS

BEHAVIORAL DIRECT PARENTS

INHIBITION MODELLING WITH
MATERNAL PANIC
ATTACHMENT
DISORDER
EXTERNAL LIFE
ANXIETY
STRESSES
DISORDER
TEMPERAMENTAL
TENDENCY AGORAPHOBIA
 DIAGNOSTIC CRITERIA
DSM-IV(F 93.0)
3 or more of the following:
Excessive distress when separation
Persistent and excessive worry
about losing or possible harm
Worry leading to separation
(kidnap, lost)
Reluctance or refusal to go school
or else where
Fear or reluctant to be alone
Refusal to go to sleep or sleep away
from home
Repeated nightmares involving
the theme separation
Repeated complaints of physical
symptoms (headache, stomach
ache, nausea, vomit)
At least 4 weeks, onset below 18 yrs,
distress or academic & social impairment
ICD-10
At least 3 of the following :
worry about possible harm
befalling major attachment figures
worry that some untoward event
(kidnap,lost,hospitalized, killed)
persistent reluctance or refusal
to go to school
persistent reluctance or refusal
to go to sleep without a major
attachment figure;
inappropriate fear of being alone
without the major attachment
figure, at home during the day;
repeated nightmares about
separation
repeated occurrence of physical
symptoms
excessive, recurrent distress
At least 4 weeks, below 6 yrs.
 PHARMACOLOGICAL
THERAPY

FAMILY PSYCHODYNAMIC
THERAPY TREATMENT APPROACH

SOCIAL
THERAPY
PROGNOSIS

GOOD EARLY DETECTION &

TREATMENT

BAD OLDER INDIVIDUALS

EARLY ONSET BUT LATE
DIAGNOSIS