Basics
Description
Separation anxiety disorder (SAD) is defined as developmentally inappropriate fear and anxiety about being away from home and/or apart from the individuals to whom a child is most attached.
- This diagnosis should be distinguished from developmentally appropriate worries, fears, and responses to stressors.
Epidemiology
- Prevalence estimates range from 3.5 to 5.1%.
- Incidence is slightly higher in females than males.
- The mean age of onset is from 4.3 to 8.0 years, but the disorder can present at any age.
Etiology
Studies show that there are genetic and environmental precursors to the development of SAD:
- A temperament of behavioral inhibition in which a child tends to approach unfamiliar situations with distress, restraint, and avoidance has been shown to be associated with development of anxiety disorders.
- Early development of stranger anxiety
- Insecure attachment between parent and child
- Increased parental anxiety
- Parenting style of being excessively controlling and overprotective
- Exposure to negative life events or stressors
- Genetic predisposition with family history of anxiety or depression
Commonly Associated Conditions
Comorbid conditions are present in up to 80% of children with SAD, most commonly including the following:
- Depression
- Simple phobia
- Social phobia
- Generalized anxiety disorder
- Obsessive compulsive disorder
- Alcohol abuse in adolescence
Diagnosis
- Anxiety with separation is a normative part of development, typically beginning around 6 or 7 months of age, peaking around 18 months and decreasing after 30 months.
- Normal separation anxiety at 6 " 7 months manifests as shyness and anxiety with strangers.
- At 12 " 18 months of age, children may have sleep disturbances, nightmares or nocturnal panic attacks, and oppositional behavior.
- SAD is distinguished by anxiety that becomes maladaptive, interfering with normal functioning or becomes overly frequent, severe, and persistent.
- DSM-IV criteria are as follows:
- Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached as evidenced by 3 (or more) of the following:
- Recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated
- Persistent and excessive worry about losing, or about possible harm befalling, major attachment figures
- Persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped)
- Persistent reluctance or refusal to go to school or elsewhere because of fear of separation
- Persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings
- Persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home
- Repeated nightmares involving the theme of separation
- Repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated
- Duration of disturbance is at least 4 weeks.
- Onset is before age 18 years.
- Disturbance causes clinically significant distress or impairment in social, academic, or other important areas (occupational).
History
- Ask parents about the specific behaviors/complaints of the child at separation, including protests (tantrums/pleading negotiating), fearfulness, or somatic complaints.
- Somatic complaints such as stomachaches and headaches are most typical.
- Ask caregivers what situations are impacted. Settings can include the following:
- Separation for school or social/extracurricular activities
- When the caregiver leaves the home
- Being separated within the home (e.g., in another room from caregiver)
- Bedtime
- Ask if sleep is impacted; specifically, ask about nightmares.
- Children with SAD often have nightmares about separation, death, kidnapping, or serious accident.
- Ask if school attendance is impacted.
- Avoidance behaviors such as procrastination during the morning routine before school or refusing to leave the side of a parent is common.
- School refusal has been reported to occur in approximately 75% of children with SAD.
- Ask about duration.
- Transient separation fears are common. In SAD, symptoms must last more than 4 weeks.
- Ask about possible stressors.
- Symptoms may be precipitated by a stressor in some cases.
- Ask about impact.
- Interferes with normative development in a number of ways such as difficulty attending school, participating in extracurricular activities, and attending sleepovers
- Bedtime separation anxiety may result in sleep disruption to child and family.
Physical Exam
There are no pertinent findings on physical exam.
Diagnostic Tests & Interpretation
- There are no pertinent findings on lab work.
- There is no standard tool for diagnosis.
- There are a variety of scales that can help in the diagnosis, including the Separation Anxiety Assessment Scale, which has both child and parent versions.
Differential Diagnosis
SAD should be distinguished from normal, developmentally appropriate separation anxiety. Additionally, one should consider possible life stressors or abuse. Alternate anxiety disorders include the following:
- Generalized anxiety disorder
- Distinguished by anxiety that is generalized and often presents in later adolescence
- In children, this tends to manifest as excessive concern over the quality of school or athletic performance at school, concern about punctuality, or overzealous in seeking of approval from authority figures.
- Social anxiety
- Presents as fear or avoidance of social situations in general or specific situations (e.g., eating in public)
- Specific phobias
- Occur when anxiety is due to a specific object or situation; unlike in adults, children may not recognize their anxiety/fear of the specific item as excessive
Treatment
Initial treatment should include psychoeducation for the caregiver (who will need to implement changes with the child) and cognitive behavioral techniques for the child.
- Psychoeducation for the caregiver includes explanations of the following:
- The normative nature of anxiety
- Caregiver response to child 's protests and fears can inadvertently reinforce the child 's separation behaviors.
- Specific advice to caregivers:
- Do not prolong a good-bye:
- Be brief.
- Let the child know when you will return.
- Reassure the child that you know that he/she will be ok.
- Do not let the child see you are upset at the separation.
- Do not overdo the reunion.
- If a child is having extreme difficulties:
- Start with smaller separations.
- Use incentives and positive reinforcement for success (e.g., sticker charts or points).
- Gradually build to larger separations.
- Anxiety workbooks can be used by the caregiver at home to provide activities for relaxation and reducing stress.
- Caregivers may need treatment for anxiety if their own anxiety seems to be contributing to the child 's behavior.
- Cognitive behavioral therapy (CBT) with the child is aimed at helping the child evaluate the accuracy of his or her fears and learn helpful self-talk.
Medication
Psychopharmacology should generally be used for separation anxiety only if nonmedication treatment is insufficient or if there are additional comorbid anxiety diagnoses that are significantly impairing and psychosocial treatments are simultaneously being pursued.
- Selective serotonin reuptake inhibitor (SSRIs) medications are the primary choice for anxiety disorders in children.
- Young children (<10 years of age) are at increased risk of side effects with SSRI medications.
- As a result, slow dosing and frequent monitoring is needed.
- Side effects include GI upset, headaches, dizziness, and agitation.
- SSRI medications have an FDA black box warning due to an increase in suicidal thinking and behavior in children and adolescents; monitoring recommendations need to be followed.
Issues for Referral
If improvement is not seen within a month after providing education and guidance to caregiver, a referral to a mental health provider is indicated.
- A referral should be made to a mental health provider before medications would be considered for SAD.
- Treatment is usually brief for uncomplicated SAD. Therapy 1 " 2 times per week may last 6 " 12 weeks.
Ongoing Care
Follow-up Recommendations
- If impairing symptoms continue for more than a month, a higher level of intervention may be indicated.
- If medications are started for anxiety in children, monitoring on a weekly basis is needed for at least 4 weeks after the medication is started or increased and monthly thereafter. (See FDA guidelines for specific medications.)
Prognosis
Outcomes are good with intervention.
- Children with SAD are at higher lifetime risk for other mental health conditions, particularly panic disorders.
- SAD can continue through childhood and into adulthood; early identification and intervention is important to minimize morbidity.
Additional Reading
- Brewer S, Sarvet B. Management of anxiety disorders in the pediatric primary care setting. Pediatr Ann. 2011;40(11):541 " 547. [View Abstract]
- Eisen AR, Schaefer CE. Separation Anxiety in Children and Adolescents: An Individualized Approach to Assessment and Treatment. New York: The Guilford Press; 2005.
- Ost L-G, Treffers P. Onset, course and outcome for anxiety disorders in children. In: Silverman W, Cambridge P, eds. Anxiety Disorders in Children and Adolescents: Research, Assessment and Intervention. Cambridge, United Kingdom: Cambridge University Press; 2001.
- DSM-IV
Codes
ICD09
- 309.21 Separation anxiety disorder
ICD10
- F93.0 Separation anxiety disorder of childhood
SNOMED
- 11806006 separation anxiety disorder of childhood (disorder)
FAQ
- Q: How do I know if it is developmentally normal separation anxiety?
- A: When separation anxiety arises after the age of 6 years, it warrants intervention if it lasts for more than 4 weeks and/or is markedly impacting expected activities. Before the age of 6 years, separation fears are more common but warrant intervention if impairment in normal functioning is seen.
- Q: Can a teenager have SAD?
- A: Yes. SAD can affect a child of any age and can even persist into adulthood.
- Q: What type of mental health provider can treat SAD that does not respond to primary care intervention?
- A: Any master 's or doctorate level mental health provider with experience in anxiety disorders in children and behavioral techniques such as CBT.