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Separation Anxiety

Almost all young infants experience anxiety during the earliest separations from their caretakers. Sometimes separation anxiety can continue beyond the expected age and interfere with a child's ability to function. Separation anxiety can be expected to begin to resolve for most children at 18 months of age.

Separation Anxiety Disorder is a specific psychiatric diagnosis consisting of separation anxiety starting at preschool or thereafter. Separation anxiety disorder may prevent a child from achieving critical developmental milestones, such as leaving his parent to go to school.

Diagnosis

The diagnosis of separation anxiety disorder should be based on information from multiple persons, including the parents, teachers, and child. Separation anxiety disorder may also present as misbehavior, opposition, or poor academic performance.

Important features of the criteria include the worry about possible harm befalling a major attachment figure, worry about past events, refusal to go to school, and fear of going to sleep without being near a parent.

A child who has separation anxiety disorder will usually appear physically clinging to or shadowing a parent, or refuse to go outside to play or to watch television in another room.

For some children, the disorder may be exacerbated by depression or by family dysfunction.

Differential Diagnosis

School phobia is characterized by fear of something at school (eg, a bully), not fear of separation from parents. School refusal is related to a specific reason for refusing to attend school, such as fear of failure or dislike of a teacher.

Depression or anxiety disorders may coexist with and exacerbate separation anxiety.

DSM-IV Diagnostic Criteria for Separation Anxiety Disorder

A. Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three or more of the following:

(1) recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated

(2) persistent and excessive worry about losing, or about possible harm befalling, major attachment figures

(3) persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (eg, getting lost or being kidnaped)

(4) persistent reluctance or refusal to go to school or elsewhere because of fear of separation

(5) persistently and excessively tearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings

(6) persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home

(7) repeated nightmares involving the theme of separation

(8) repeated complaints of physical symptoms (such as headaches, stomachaches, or nausea) when separation from major attachment figures occurs or is anticipated

B. The duration of the disturbance is at least 4 weeks.

C. The onset is before age 18 years.

D. The disturbance causes clinically significant distress or impairment in social, or academic functioning.

E. The disturbance does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia or other psychotic disorder and, in adolescents, is not better accounted for by panic disorder with agoraphobia.

Treatment

Consistency of parental behavior should be maintained (eg, the child should always be picked up from school at the time promised). For some children, a transitional object, such as a blanket becomes a substitute for the parents' presence.

Playing with friends and being in different rooms at home are useful for gradually increasing separation.

A child who is having difficulty returning to school may need to be accompanied by a parent who will remain at school initially, then on subsequent days retreat further from the classroom until the child can be left at school.

Behavior therapy involves systematic desensitization, whereby the child is gradually introduced to situations that are progressively more anxiety-provoking. At each level, the child is taught how to use breathing, imagination, and relaxation techniques to control uncomfortable feelings.

Behavior therapy rewards the child's independent behaviors by giving rewards for school attendance.

Treatment with alprazolam, imipramine, or clonazepam has resulted in significant improvement.

Prognosis

Separation anxiety is a normal part of development and usually resolves without specific treatment in most children.

Exacerbations may occur during times of increased stress (changing schools, divorce, changing residences).