ANXIETY DISORDERS
Chapter F.2

SEPARATIONANXIETY

Ana Figueroa,
Cesar Soutullo,
Yoshiro Ono &Kazuhiko Saito
DEPRESSION IN CHILDREN AND
ADOLESCENTS

Adapted by Julie Chilton

The “IACAPAP Textbook of Child and Adolescent Mental Health” is available at theIACAPAP website http://iacapap.org/iacapap-textbook-of-child-and-adolescentmental-health

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• The Basics• Clinical Presentation• Diagnostic Criteria• Epidemiology• Etiology• Comorbidity• Diagnosis• Treatment• Cross-Cultural
Syndromes

Separation Anxiety Disorder (SAD):– Abnormal reactivity to real or
imagined separation fromattachment figures– Interferes with daily activities
and development– Lasts longer than 4 weeks– Begin before age 18– Significant distress orimpairment– Beyond what is expected atdevelopmental stage

https://www.youtube.com/watch?v=58khDBvteTs&f
eature=related• A common psychopathology in youth• Prevalence: 5-25% worldwide• Much lower percentage get treatment• Usually not assessed till refusing school orsomatic symptoms• Accounts for half of all anxiety referrals• Different diagnostic criteria than in adults• Negative psychosocial outcomes• Predictive of adult pathology especially panic
disorder• Heterogeneous• Cardinal symptom = excessive distress or fearwith separation from attachment figures• 3 characteristics:– 1) excessive or persistent fears or worries before andat the time of separation– 2) behavioral and somatic symptoms before, during,
and after separation– 3) persistent avoidance or attempts to escape theseparation situation

Worries:• Something
happen to parents– Disappear– Get lost
– Forget child– Physical safety• Something
happen to child– Get lost
– Kidnapped– Killed

Behaviors:• Crying• Clinging• Complaining• Searching• Calling

Physical symptoms:• Headaches• Abdominal pain
• Fainting, dizziness• Nightmares, sleep
problems• Nausea, vomiting• Cramps, muscleaches• Palpitations, chestpain• 3 of 8 persistent, recurrent
and excessive anxiety:--Distress with separation--Worry about losing or
harm to attachment figures--Worry about getting lostor kidnapped--School/work refusal--Being alone or away fromcaregivers--Sleeping away fromcaregivers--Separation nightmares--Physical complaints• Symptoms at least 4 weeks• Begins before age 18• Not explained by anotherpsychiatric disorder• Moderate impairment or worse••••••••••••Day care drop-off
Entering school
Boarding school bus
BedtimeLeft at home with babysitter
Summer camp
MovingSpending the night out
During parental separation or divorce
Change in friends
Bullying
Medical illness••••
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Scarce data
Peak onset between ages 7 to 9
3-5% prevalence, decreasing with age
Most common anxiety disorder of childhood
Usually resolves by adolescence
1/3 childhood cases persist into adulthood if untreated
7th most common lifetime disorder
Adult prevalence 6%
Sub-threshold SAD much more commonPossibly more common in girls, African-Americans and low
socio-economic status within US•
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Some anxiety at separation developmentally normal
Usually peaks at 9-13 months of age
Decreases after age 2
Increased autonomy at age 3
Increases again at age 4-5
Parental anxiety disorder  persistent SAD in child• Genetics• Decreased exposure to separation• Diagnosis not made before age 5

Child/Adolescent Anxiety Multimodal Study(CAMS):• Younger age• Non-minority status• Lower severity at baseline• Absence of other internalizing disorders• Absence of social phobia

• Both biological and environmental factors• Large scale twin study: heritability 73%(Bolton et al, 2006)• Anxiety disorders 5 x more likely if anxious
parents• Fear conditioning in fear reward circuits(amygdala, orbitofrontal cortex, anterior
cingulate cortex)

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Low parental warmthLittle child autonomy
Overprotective and overinvolved parents
Insecure attachment, especially with motherAnxious mothers
Severe parental discord
Separation or divorce
Parental physical illnessParental mental illness
Parental job loss
Egocentric, immature, instable or antisocial father
Exposure to family violence
Birth of a sibling• Stressful life events: major disaster orcrime• Behavioral inhibition• Low tolerance for humiliation• Fear of failure• Depression• Females > males• Being bullied• Low achievement in school and sports• Other anxiety disorders• Depression• Disruptive behavior disorders• Specific phobias• School avoidance• Major depression• Bipolar disorder• Attention deficit hyperactivity disorder• Assess: behaviors, thoughts, physical symptoms• Multi-informant, multi-method approach: child, school,
caregivers• Structured or semi-structured interview ideal:• Anxiety Disorder Interview Schedule for DSM-IV Childand Parent Version (ADIS-IV-C/P)• Kiddie Schedule of Affective Disorders and Schizophrenia
for School age Children, Present and Lifetime version (KSADS-PL)• The Preschool Age Psychiatric Assessment (PAPA)• Normal development• Medical illness• Other anxiety disorders: social phobia, generalized anxietydisorder• Depression• Substance use: cannabis, cocaine, caffeine, alcohol• Inappropriate educational placement• Violence or bullying at school• Grief reaction• Truancy• Anemia• Infections• Hyperthyroidism• Mitral valve prolapse• Asthma• Gastrointestinal issues• Diabetes mellitus• Lead and mercury levels• Brain tumor• Seizure disorder• BUT AVOID UNNECESSARY INVESTIGATIONS• Psychoeducation• Behavioral management• Interventions at school• Interventions at home
• Cognitive Behavioral Therapy• Pharmacological treatment

• The Basics• Clinical Presentation• Diagnostic Criteria• Epidemiology• Etiology• Comorbidity• Diagnosis• Treatment• Cross-Cultural
Syndromes• Listen empathically• Model calm
• Reminders of past success• Teach relaxation• Plan transitions• List strategies• Return to school ASAP!
• Encourage activities without parent• Discourage avoidance• Praise efforts• Reframe somatic symptoms

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Plan for return to school ASAP!
Frequent meetings
Assess and address cause
Supervised daily arrival
Attachment figure initially allowed
Slow increase of school day length
Identify safe place
Relaxation techniques from home
Alternative activities to distract from physical symptoms
Encourage small groups
Reward efforts
Prepare for transitions• Most effective evidence-based therapy• Short and long term benefits• Based on: classical, operant, social learning• Targets: gain insight, control worries, reduce arousal,
confront fears• Methods: psychoeducation, cognitive restructuring,skill building, relaxation training, modeling,
contingency management, exposure and response
prevention• Examples: Coping Cat, Friends, Camp-like CBT, ParentChild Interaction Therapy (PCIT), CALM program• Family involvement is key• Autonomy• Supervision level• Sleeping practices• Size of house• Role of parents inchildcare

Japanese terminology:• tokokyohi• futoko• hikikomori• School refusal• Truancy• Social phobia• Refusal to go to school• School non-attendance• School phobia