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Key Features

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Essentials of Diagnosis
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  • Persistent excessive worry about losing or being separated from attachment figures, due to harm, illness, or death befalling either the attachment figure or the patient

  • Reluctance or refusal to leave the attachment figure or sleep away from the attachment figure

  • Fear of being home without attachment figure

  • Physical complaints when separation occurs or is anticipated

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General Considerations
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  • Anxiety about separation from attachment figures is part of early normative development

  • More prevalent in younger children (4% 6-month prevalence compared with 1.6% 6-month prevalence in adolescence)

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Clinical Findings

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Symptoms and Signs
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  • Must be distinguished from normal development

  • Must occur for more than 4 weeks for children

  • Must lead to impairment or significant distress

  • Younger children may not be symptomatic until the separation is imminent, and may not experience explicit fears related to separation

  • As children get older, they may experience specific fears such as fears of kidnapping, parents getting into car accidents, being separated due to natural disasters, etc

  • In addition to appearing anxious, children with separation anxiety can appear sad, aggressive, or experience physical symptoms when facing the anxiety provoking separation

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Differential Diagnosis
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  • Other anxiety disorders

  • Mood disorders

  • Oppositional defiant disorder

  • Conduct disorder

  • Psychotic disorder

  • Personality disorders

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Diagnosis

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  • Pediatricians are likely to encounter children with school refusal, a common behavioral manifestation of separation anxiety

  • Symptoms of school refusal often include physical symptoms and or behavioral outbursts as school time approaches

  • Parents often notice symptoms abate on the weekend, vacations, or if the child is no longer expected to attend school

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Treatment

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  • Mild cases may be handled with the help of the pediatrician's office, but more severe cases may need the help of a mental health specialist

  • Cognitive-behavioral therapy that is modified to address the developmental level of the child

  • Children who do not respond to therapy may require medication such as a selective serotonin reuptake inhibitor

  • Children younger than school age generally are not treated with medication

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Outcome

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Prognosis
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  • Separation anxiety often abates by adolescence, but adolescents who experienced separation anxiety disorder in childhood are at increased risk for other disorders

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References

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American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA, American Psychiatric Association; 2013.
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Beesdo-Baum  K, Knappe  S: Developmental epidemiology of anxiety disorder. Child Adolesc Psychiatric Clin N Am 2012;21:457–478
[PubMed: 22800989] .
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Ghandhi  B, Cheek  S, Campo  JV: Anxiety in the pediatric medical setting. Child Adolesc Psychiatric Clin N Am 2012;21:643–653
[PubMed: 22800999] .
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Ginsberg  GS, Kendall  PC, Sakolsky  D  et al: Remission after acute treatment in children and adolescents with ...

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