Anxiety, Separation

Key Features

Essentials of Diagnosis

• 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

General Considerations

• 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)

Clinical Findings

Symptoms and Signs

• 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

Differential Diagnosis

• Other anxiety disorders

• Mood disorders

• Oppositional defiant disorder

• Conduct disorder

• Psychotic disorder

• Personality disorders

Diagnosis

• 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

Treatment

• 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

Outcome

Prognosis

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

References