Advertisement

Separation Anxiety Disorder

  • Aleta G. Angelosante
  • Magdalena A. Ostrowski
  • Rachel R. Chizkov
Chapter
Part of the Current Clinical Psychiatry book series (CCPSY)

Abstract

Separation anxiety disorder (SAD) is one of the most commonly diagnosed anxiety disorders among children presenting for treatment. A child with SAD experiences excessive anxiety concerning separation from home or from caregivers as well as persistent, unrealistic worry about harm to self or loved ones. Fears may manifest as an unwillingness to leave home, reluctance to be alone, physical complaints around separation, and frequent reassurance seeking regarding safety. This chapter provides a review of the current literature regarding the course and etiology of SAD, with a focus on genetic studies, environmental factors, and parenting. The link between childhood SAD, panic disorder, and other forms of psychopathology in adulthood is also considered. Assessment and treatment of SAD are discussed, with a review of the empirical evidence for the use of traditional cognitive-behavioral therapy (CBT), camp-based CBT, modified parent–child interaction therapy, and psychopharmacological treatments. Research on assessments and treatments specifically for SAD has been scarce. Given the relatively high prevalence of this disorder, and its role as a predictor of later psychopathology, further study is warranted. Future research might examine treatments designed specifically for SAD or recruit a subject pool that would allow for independent investigation of results for those with SAD within a larger heterogeneous anxiety sample. Furthermore, additional attempts to understand SAD as a risk factor may lead to prevention of adult psychopathology in these children.

Keywords

Separation anxiety disorder Children Etiology Course Cognitive-behavioral therapy Parent–child interaction therapy 

References

  1. 1.
    Marks I. The development of normal fear: a review. J Child Psychol Psychiatry. 1987;28:667–97.PubMedCrossRefGoogle Scholar
  2. 2.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th edition—text revision). Washington, DC: Author; 2000.CrossRefGoogle Scholar
  3. 3.
    Francis G, Last CG, Strauss CC. Expression of separation anxiety disorder: the roles of gender and age. Child Psychiatry Hum Dev. 1987;18:82–9.PubMedCrossRefGoogle Scholar
  4. 4.
    Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distribution of DSM-IV Disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:593–602.PubMedCrossRefGoogle Scholar
  5. 5.
    Last CG, Perrin S, Hersen M, et al. DSM-III-R anxiety disorders in children: sociodemographic and clinical characteristics. J Am Acad Child Adolesc Psychiatry. 1992;31:1070–6.PubMedCrossRefGoogle Scholar
  6. 6.
    Costello EJ, Mustillo S, Erkanli A, Keeler G, Angold A. Prevalence and development of psychiatric disorders in children and adolescents. Arch Gen Psychiatry. 2003;60:837–44.PubMedCrossRefGoogle Scholar
  7. 7.
    Last CG, Hersen M, Kazdin AE, Francis G, Grubb HJ. Psychiatric illness in the mothers of anxious children. Am J Psychiatry. 1987;144:1580–3.PubMedGoogle Scholar
  8. 8.
    Anderson JC, Williams S, McGee R, Silva PA. DSM-III disorders in preadolescent children. Prevalence in a large sample from the general population. Arch Gen Psychiatry. 1987;44(1):69–76.PubMedCrossRefGoogle Scholar
  9. 9.
    Costello EJ. Developments in child psychiatric epidemiology. J Am Acad Child Adolesc Psychiatry. 1989;28(6):836–41.PubMedCrossRefGoogle Scholar
  10. 10.
    Foley DL, Pickles A, Maes HM, Silberg JL, Eaves LJ. Course and short-term outcomes of separation anxiety disorder in a community sample of twins. J Am Acad Child Adolesc Psychiatry. 2004;43(9):1107–14. doi: 10.1097/01.chi.0000131138.16734.f4.PubMedCrossRefGoogle Scholar
  11. 11.
    Aschenbrand SG, Kendall PC, Webb A, Safford SM, Flannery-Schroeder E. Is childhood separation anxiety disorder a predictor of adult panic disorder and agoraphobia? A seven-year follow-up study. J Am Acad Child Adolesc Psychiatry. 2003;42:1478–85.PubMedCrossRefGoogle Scholar
  12. 12.
    Lipsitz JD, Martin LY, Mannuzza S, Chapman TF, Liebowitz MR, Klein DF, et al. Childhood separation anxiety disorder in patients with adult anxiety disorders. Am J Psychiatry. 1994;151:927–9.PubMedGoogle Scholar
  13. 13.
    Biederman J, Petty C, Faraone SV, Hirshfeld-Becker DR, Henin A, Rauf A, et al. Childhood antecedents to panic disorder in referred and non-referred adults. J Child Adolesc Psychopharmacol. 2005;15:549–61.PubMedCrossRefGoogle Scholar
  14. 14.
    Biederman J, Petty C, Faraone SV, Hirshfeld-Becker DR, Henin A, Brauer L, et al. Antecedents to panic disorder in non-referred adults. J Clin Psychiatry. 2007;67:1179–86.CrossRefGoogle Scholar
  15. 15.
    Klein DF. Delineation of two drug-responsive anxiety syndromes. Psychopharmacology. 1964;3:397–408.CrossRefGoogle Scholar
  16. 16.
    Lewinsohn PM, Holm-Denoma JM, Small JW, Seeley JR, Joiner Jr TE. Separation anxiety disorder in childhood as a risk factor for future mental illness. J Am Acad Child Adolesc Psychiatry. 2008;47(5):548–55. doi: 10.1097/CHI.0b013e31816765e7.PubMedCrossRefGoogle Scholar
  17. 17.
    Otto MW, Pollack MH, Maki KM, Gould RA, Worthington J, Smoller JW, et al. Childhood history of anxiety disorders among adults with social phobia: rates, correlates, and comparisons with patients with panic disorder. Depress Anxiety. 2001;14(4):209–13. doi: 10.1002/da.1068.PubMedCrossRefGoogle Scholar
  18. 18.
    Gorman JM, Kent J, Martinez J, Browne S, Coplan J, Papp LA. Physiological changes during carbon dioxide inhalation in patients with panic disorder, major depression, and premenstrual dysphoric disorder: evidence for a central fear mechanism. Arch Gen Psychiatry. 2001;58(2):125–31.PubMedCrossRefGoogle Scholar
  19. 19.
    Kent JM, Papp LA, Martinez JM, Browne ST, Coplan JD, Klein DF, et al. Specificity of panic response to CO2 inhalation in panic disorder: a comparison with major depression and premenstrual dysphoric disorder. Am J Psychiatry. 2001;158:58–67. doi: 10.1176/appi.ajp.158.1.58.PubMedCrossRefGoogle Scholar
  20. 20.
    Papp LA, Klein DF, Gorman JM. Carbon dioxide hypersensitivity, hyperventilation, and panic disorder. Am J Psychiatry. 1993;150(8):1149–57.PubMedGoogle Scholar
  21. 21.
    Pine DS, Klein RG, Roberson-Nay R, Mannuzza S, Moulton JL, Woldehawariat G, et al. Response to 5% carbon dioxide in children and adolescents: relationship to panic disorder in parents and anxiety disorders in subjects. Arch Gen Psychiatry. 2005;62(1):73–80.PubMedCrossRefGoogle Scholar
  22. 22.
    Roberson-Nay R, Klein DF, Klein RG, Mannuzza S, Moulton JL, Guardino M, et al. Carbon dioxide hypersensitivity in separation-anxious offspring of parents with panic disorder. Biol Psychol. 2010;67(12):1171–77.Google Scholar
  23. 23.
    Pine DS, Cohen P, Gurley D, Brook J, Ma Y. The risk of early-adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders. Arch Gen Psychiatry. 1998;55:56–64.PubMedCrossRefGoogle Scholar
  24. 24.
    Last CG, Strauss CC, Francis G. Comorbidity among child anxiety disorders. J Nerv Ment Dis. 1987;175:726–30.PubMedCrossRefGoogle Scholar
  25. 25.
    Masi G, Favilla L, Mucci M, Millepiedi S. Depressive comorbidity in children and adolescents with generalized anxiety disorder. Child Psychiatry Hum Dev. 2000;30(3):205–15.PubMedCrossRefGoogle Scholar
  26. 26.
    Kearny CA, Albano AM. The functional profiles of school refusal behavior. Behav Modif. 2004;28(1):147–61.CrossRefGoogle Scholar
  27. 27.
    Doerfler LA, Toscano PF, Connor DF. Separation anxiety and panic disorder in clinically referred youth. J Anxiety Disord. 2008;22(4):602–11.Google Scholar
  28. 28.
    Weissman MM, Leckman JF, Merikangas KR, Gammon GD, Prusoff BA. Depression and anxiety disorders in parents and children: results from the Yale family study. Arch Gen Psychiatry. 1984;41:845–52.PubMedCrossRefGoogle Scholar
  29. 29.
    Biederman J, Faraone SV, Hirshfeld-Becker DR, Friedman D, Robin JA, Rosenbaum JF. Patterns of psychopathology and dysfunction in high-risk children of parents with panic disorder and major depression. Am J Psychiatry. 2001;158:49–57.PubMedCrossRefGoogle Scholar
  30. 30.
    Feigon SA, Waldman ID, Levy F, Hay DA. Genetic and environmental influences on separation anxiety disorder symptoms and their moderation by age and sex. Behav Genet. 1997;31(5):401–11.Google Scholar
  31. 31.
    Cronk NJ, Slutske WS, Madden PA, Bucholz KK, Heath AC. Risk for separation anxiety disorder among girls: paternal absence, socioeconomic disadvantage, and genetic vulnerability. J Abnorm Psychol. 2004;113(2):237–47.PubMedCrossRefGoogle Scholar
  32. 32.
    Topolski TD, Hewitt JK, Eaves JL, Silberg JL, Meyer JM, Rutter M, et al. Genetic and environmental influences on child reports of manifest anxiety and symptoms of separation anxiety and overanxious disorders: a community-based twin study. Behav Genet. 1997;27(1):15–28.PubMedCrossRefGoogle Scholar
  33. 33.
    Brand S, Wilhelmb FH, Kossowsky J, Holsboer-Trachsler E, Schneider S. Children suffering from separation anxiety disorder (SAD) show increased HPA axis activity compared to healthy controls. J Psychiatr Res. 2011;45(4):452–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Dumas JE, LaFreniere PJ. Mother-child relationships as sources of support or stress: a comparison of competent, average, aggressive, and anxious dyads. Child Dev. 1993;64(6):1732–54.PubMedCrossRefGoogle Scholar
  35. 35.
    Hudson JL, Rapee RM. Parent–child interactions and anxiety disorders: an observational study. Behav Res Ther. 2001;39(12):1411–27.PubMedCrossRefGoogle Scholar
  36. 36.
    Sigueland L, Kendal PC, Steinberg L. Anxiety in children: perceived family environments and observed family interaction. J Clin Child Psychol. 1996;25(2).Google Scholar
  37. 37.
    Wijsbroek SAM, Hale WW, Raaijmakers QAW, Meeus WHJ. The direction of effects between perceived parental behavioral control and psychological control and adolescents’ self-reported GAD and SAD symptoms. Eur Child Adolesc Psychiatry. 2011;20:361–71.Google Scholar
  38. 38.
    Barrett PM, Dadds MR, Rapee RM. Family treatment of childhood anxiety: a controlled trial. J Consult Clin Psychol. 1996;64:333–42.PubMedCrossRefGoogle Scholar
  39. 39.
    Poulton R, Milne BJ, Craske MG, Menzies RG. A longitudinal study of the etiology of separation anxiety. Behav Res Ther. 2001;39(12):1395–410. doi: 10.1016/S0005-7967(00),00105-4.PubMedCrossRefGoogle Scholar
  40. 40.
    Lavallee K, Herren C, Blatter-Meunier J, Adornetto C, In-Albon T, Schneider S. Early predictors of separation anxiety disorder: Early stranger anxiety, parental pathology and prenatal factors. Psychopathology. 2011;44(6):354–61.Google Scholar
  41. 41.
    March JS, Parker JDA, Sullivan K, Stallings P, Connors CK. The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity. J Am Acad Child Adolesc Anxiety. 1997;36:554–65.CrossRefGoogle Scholar
  42. 42.
    March JS, Parker JDA, Sullivan K. Test-retest reliability of the Multidimensional Anxiety Scale for Children. J Anxiety Disord. 1999;13:349–58.PubMedCrossRefGoogle Scholar
  43. 43.
    Birmaher B, Khetarpal S, Brent D, Cully M, Balach L, Kaufman J, et al. The screen for child anxiety related emotional disorders: scale construction and psychometric characteristics. J Am Assoc Child Adolesc Psychiatry. 1997;36:545–53.CrossRefGoogle Scholar
  44. 44.
    Muris P, Steerneman P. The Revised version of the Screen for Child Anxiety Related Emotional Disorders (SCARED-R): First evidence for its reliability and validity in a clinical sample. Br J Clin Psychol. 2001;40:35–44.PubMedCrossRefGoogle Scholar
  45. 45.
    Spence S. A measure of anxiety symptoms among children. Behav Res Ther. 1998;36:545–66.PubMedCrossRefGoogle Scholar
  46. 46.
    Schneider S, Blatter-Meunier J, Herren C, Adornetto C, In-Albon T, Lavallee K. Disorder-specific cognitive-behavioral therapy for separation anxiety disorder in young children: a Randomized waiting-list-controlled trial. Psychother Psychosom. 2011;80:206–15.PubMedCrossRefGoogle Scholar
  47. 47.
    Silverman WK, Pina AA, Viswesvaran C. Evidence-based psychosocial treatments for phobic and anxiety disorders in children and adolescents. J Clin Child Adolesc Psychol. 2008;37:105–30.PubMedCrossRefGoogle Scholar
  48. 48.
    Chambless DL, Sanderson WC, Shoham V, Johnson SB, Pope KS, Crits-Christoph P, et al. An update on empirically validated therapies. Clin Psychol. 1996;49:5–18.Google Scholar
  49. 49.
    Chambless DL, Hollon SD. Defining empirically supported therapies. J Consult Clin Psychol. 1998;66:7–18.PubMedCrossRefGoogle Scholar
  50. 50.
    Barrett PM. Evaluation of cognitive-behavioral group treatments for childhood anxiety disorders. J Clin Child Psychol. 1998;27:459–68.PubMedCrossRefGoogle Scholar
  51. 51.
    Barrett PM, Duffy AL, Dadds MR, Rapee RM. Cognitive-behavioral treatment of anxiety disorders in children: long-term (6-year) follow-up. J Consult Clin Psychol. 2001;69:135–41.PubMedCrossRefGoogle Scholar
  52. 52.
    Bodden D, Bogels SM, Nauta MH, De Haan E, Ringrose J, Appelboom C, et al. Child versus family cognitive-behavioral therapy in clinically anxious youth: an efficacy and partial effectiveness study. J Am Acad Child Adolesc Psychiatry. 2008;47(12):1384–94.PubMedCrossRefGoogle Scholar
  53. 53.
    Bögels SM, Siqueland L. Family cognitive behavioral therapy for children and adolescents with clinical anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2006;45:134–41.PubMedCrossRefGoogle Scholar
  54. 54.
    Flannery-Schroeder EC, Kendall PC. Group and individual cognitive-behavioral treatments for youth with anxiety disorders: a randomized clinical trial. Cognit Ther Res. 2000;24:251–78.CrossRefGoogle Scholar
  55. 55.
    Kendall PC. Coping cat workbook. Ardmore: Workbook Publishing; 1990.Google Scholar
  56. 56.
    Kendall PC. Treating anxiety disorders in children: results of a randomized clinical trial. J Consult Clin Psychol. 1994;62:100–10.PubMedCrossRefGoogle Scholar
  57. 57.
    Kendall PC, Flannery-Schroeder E, Panichelli-Mindel SM, Southam-Gerow M, Henin A, Warman M. Therapy for youths with anxiety disorders: a second randomized clinical trial. J Consult Clin Psychol. 1997;65:366–80.PubMedCrossRefGoogle Scholar
  58. 58.
    Kendall PC, Hudson JL, Gosch E, Flannery-Schroeder E, Suveg C. Cognitive-behavioral therapy for anxiety disordered youth: a randomized clinical trial evaluating child and family modalities. J Consult Clin Psychol. 2008;76:282–97.PubMedCrossRefGoogle Scholar
  59. 59.
    Manassis K, Mendlowitz SL, Scapillato D, Avery D, Fiksenbaum L, Freire M, et al. Group and individual cognitive-behavioral therapy for childhood anxiety disorders. A randomized trial. J Am Acad Child Adolesc Psychiatry. 2002;41:1423–30.PubMedCrossRefGoogle Scholar
  60. 60.
    Muris P, Mayer B, Bartelds E, Tierney S, Bogie N. The revised version of the Screen for Child Anxiety Related Emotional Disorders (SCARED-R): treatment sensitivity in an early intervention trial for childhood anxiety disorders. Br J Clin Psychol. 2001;40:323–36.PubMedCrossRefGoogle Scholar
  61. 61.
    Muris P, Meesters C, van Melick M. Treatment of childhood anxiety disorders; a preliminary comparison between cognitive-behavioral group therapy and a psychological placebo intervention. J Behav Ther Exp Psychiatry. 2002;33:143–58.PubMedCrossRefGoogle Scholar
  62. 62.
    Saavedra LM, Silverman WK, Morgan-Lopez AA, Kurtines WM. Cognitive behavioral treatment for childhood anxiety disorders: long-term effects on anxiety and secondary disorders in young adulthood. J Child Psychol Psychiatry. 2010;51:924–34.PubMedCrossRefGoogle Scholar
  63. 63.
    Shortt AL, Barrett PM, Fox TL. Evaluating the FRIENDS program: a cognitive-behavioral group treatment for anxious children and their parents. J Clin Child Psychol. 2001;30:525–35.PubMedCrossRefGoogle Scholar
  64. 64.
    Thienemann M, Moore P, Tompkins K. A parent-only group intervention for children with anxiety disorders: pilot study. J Am Acad Child Adolesc Psychiatry. 2006;45:37–46.PubMedCrossRefGoogle Scholar
  65. 65.
    Eisen AR, Raleigh H, Neuhoff CC. The unique impact of parent training for separation anxiety disorder in children. Behav Ther. 2008;39:195–206.PubMedCrossRefGoogle Scholar
  66. 66.
    Foote RC, Schuhmann EM, Jones ML, Eyberg SM. Parent–child interaction therapy: a guide for clinicians. Clin Child Psychol Psychiatry. 1998;3:361–73.CrossRefGoogle Scholar
  67. 67.
    Zisser A, Eyberg SM. Treating oppositional behavior in children using parent–child interaction therapy. In: Kazdin AE, Weisz JR, editors. Evidence-based psychotherapies for children and adolescents. 2nd ed. New York: Guilford; 2010. p. 179–93.Google Scholar
  68. 68.
    Choate ML, Pincus DB, Eyberg SM, Barlow DH. Parent–child interaction therapy for treatment of separation anxiety disorder in young children: a pilot study. Cogn Behav Pract. 2005;12:126–35.CrossRefGoogle Scholar
  69. 69.
    Pincus DB, Eyberg SM, Choate ML. Adapting parent–child interaction therapy for young children with separation anxiety disorder. Educ Treat Children. 2005;28:163–81.Google Scholar
  70. 70.
    Pincus DB, Santucci LC, Ehrenreich JT, Eyberg SM. The implementation of modified parent–child interaction therapy for youth with separation anxiety disorder. Cogn Behav Pract. 2008;15:118–25.CrossRefGoogle Scholar
  71. 71.
    Elkins R, McHugh R, Santucci LC, Barlow DH. Improving the transportability of CBT for internalizing disorders in children. Clin Child Fam Psychol Rev. 2011;14:161–73.PubMedCrossRefGoogle Scholar
  72. 72.
    Coles EK, Pelham WE, Gnagy EM, Burrows-MacLean L, Fabiano GA, Chacko A, et al. A controlled evaluation of behavioral treatment with children with ADHD attending a summer treatment program. J Emot Behav Disord. 2005;13:99–112.CrossRefGoogle Scholar
  73. 73.
    Sibley MH, Pelham WE, Evans SW, Gnagy EM, Ross J, Greiner AR. An evaluation of a summer treatment ­program for adolescents with ADHD. Cogn Behav Pract. 2011;18:530–44.CrossRefGoogle Scholar
  74. 74.
    Santucci LC, Ehrenreich JT, Trosper SE, Bennett SM, Pincus DB. Development and preliminary evaluation of a one-week summer treatment program for separation anxiety disorder. Cogn Behav Pract. 2009;16:317–31.PubMedCrossRefGoogle Scholar
  75. 75.
    Walkup JT, Riddle MA, Reeve EA, Yaryura-Tobias JA, Yang HM, Claghorn JL, et al. Fluvoxamine for children and adolescents with obsessive-compulsive disorder: a randomized, controlled, multicenter trial. J Am Acad Child Adolesc Psychiatry. 2001;40(2):222–9.PubMedCrossRefGoogle Scholar
  76. 76.
    Birmaher B, Waterman GS, Ryan N, Cully M, Balach L, Ingram J, et al. Fluoxetine for childhood anxiety disorders. J Am Acad Child Adolesc Psychiatry. 1994;33(7):993–9.PubMedCrossRefGoogle Scholar
  77. 77.
    Fairbanks JM, Pine DS, Tancer NK, Dummit ES, Kentgen LM, Martin J, et al. Open fluoxetine treatment of mixed anxiety disorders in children and adolescents. J Child Adolesc Psychopharmacol. 1997;7(1):17–29.PubMedCrossRefGoogle Scholar
  78. 78.
    RUPP Anxiety Study Group. Fluvoxamine for the treatment of anxiety disorders in children and adolescents. N Engl J Med. 2001;344:1279–85.Google Scholar
  79. 79.
    Gittelman-Klein R, Klein DF. School phobia: controlled imipramine treatment. Calif Med Assoc. 1971;115(3):42.Google Scholar
  80. 80.
    Klein RG, Koplewicz HS, Kanner A. Imipramine treatment of children with separation anxiety disorder. J Am Acad Child Adolesc Psychiatry. 1992;31(1):21–8.PubMedCrossRefGoogle Scholar
  81. 81.
    Berney T, Kolvin I, Bhate SR, Garside RF, Jeans J, Kay B, et al. School phobia: a therapeutic trial with clomipramine and short-term outcome. Br J Psychiatry. 1981;138:110–8.PubMedCrossRefGoogle Scholar
  82. 82.
    Bernstein GA, Garfinkel BD, Borchardt CM. Comparative studies of pharmacotherapy for school refusal. J Am Acad Child Adolesc Psychiatry. 1990;29(5):773–81.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Aleta G. Angelosante
    • 1
  • Magdalena A. Ostrowski
    • 2
  • Rachel R. Chizkov
    • 3
  1. 1.NYU Child Study Center, NYU Langone Medical CenterNew YorkUSA
  2. 2.Kean UniversityHillsideUSA
  3. 3.Department of Child and Adolescent PsychiatryNYU Langone Medical CenterNew YorkUSA

Personalised recommendations