IACAPAP Textbook of Child and Adolescent Mental Health

ANXIETY DISORDERS

Chapter

F.2

SEPARATION ANXIETY
Ana Figueroa, Cesar Soutullo, Yoshiro Ono& Kazuhiko Saito

Ana Figueroa MD
Director, Child & Adolescent
Psychiatry Unit, Hospital
Perpetuo Socorro, Las Palmas,
Gran Canaria, Spain
Conflict of interest: researchfunding from: Eli Lilly. CME:
Eli Lilly, Janssen, Shire.
Speaker: Eli Lilly, Janssen,
Shire, Spanish National HealthService

Cesar Soutullo MD, PhD
Director, Child & Adolescent
Psychiatry Unit, Departmentof Psychiatry & Medical
Psychology, University ofNavarra Clinic, Pamplona,
Spain

Children going to school in Ndola, Zambia
Photo: Jack Gin

Conflict of interest: researchfunding from Abbott, Alicia
Koplowitz Foundation,
Bristol-Myers Squibb, Eli Lilly,
Gobierno de Navarra, Carlos
III Institute (FIS), Redes

This publication is intended for professionals training or practising in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2012. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Figueroa A, Soutullo C, Ono Y, Saito K. Separation anxiety. In Rey JM (ed), IACAPAP e-Textbook of Child andAdolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions 2012.

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IACAPAP Textbook of Child and Adolescent Mental HealthAnxiety disorders are probably the most common psychopathology inyouth, with prevalence estimates ranging from 5% to 25% worldwide, but
a much lower percentage receive treatment (Boyd et al, 2000; Costello etal, 2003). Separation anxiety disorder (SAD) accounts for approximately half ofthe referrals among all anxiety disorders (Cartwright-Hatton et al, 2006). Most
pediatric anxiety disorders have the same diagnostic criteria as those in adults
except SAD, currently classified in DSM and ICD as one of the disorders usuallydiagnosed in infancy, childhood, or adolescence (Krain et al, 2007).
SAD is characterized by an abnormal reactivity to real or imagined
separation from attachment figures that significantly interferes with daily activities
and developmental tasks. To meet DSM-IV-R diagnostic criteria, the anxiety
must be beyond what is expected for the child's developmental level, last longer
than four weeks, begin before age 18 and cause significant distress or impairment(American Psychiatric Association, 2000).

Temáticas de Investigación
Cooperativa, Pfizer, PIUNA,
Stanley Medical ResearchInstitute-NAMI, and Solvay.
Consultant: Alicia Koplowitz
Foundation, Bristol-Myers
Squibb/Otsuka, Editorial
Médica Panamericana,Eli Lilly, Juste, European
Interdisciplinary Network
ADHD Quality Assurance,
Janssen, Pfizer, and Shire.
Speaker: AstraZeneca, Eli Lilly,
GlaxoSmithKline, Janssen,
Novartis, SEP-SEPB, Shire andSolvay.
Yoshiro Ono MD, PhD
Director, Wakayama Prefecture
Mental Health & Welfare
Center, Wakayama, JapanSAD can cause marked distress and impairment, can lead to several negative
psychosocial outcomes, and is predictive of adult psychiatric disorders, especiallypanic disorder. In spite of this, the disorder has seldom been studied, and children
are not usually clinically assessed until SAD results in school refusal or marked
somatic symptoms. Available effective treatments include psychotherapy andmedications.

Conflict of interest: none
declared

CLINICAL PRESENTATION

Conflict of interest: none
declared

Kazuhiko Saito MD
Director, Department of Child
Psychiatry, Kohnodai Hospital,
National Center for Global
Health and Medicine, JapanSAD has a heterogeneous clinical presentation. The cardinal symptom is asignificant or developmentally inappropriate distress, or excessive and unrealistic
fears, upon separation from attachment figures (usually parents) or the home(American Psychiatric Association, 2000). There are three key characteristics ofseparation anxiety disorder:•

Excessive and persistent fears or worries before and at the time ofseparation.

•

Behavioral and somatic symptoms before, during and after the
separation, and•Persistent avoidance or attempts to escape the separation situation.

The child worries that something may happen to his parents (e.g., thatthey will disappear, get lost or forget about him) or that the child will get lost,
kidnapped or killed if he is not near his parents. Behavioral symptoms include
crying, clinging, complaining upon separation, and searching or calling for theparent after their departure. Physical symptoms are similar to those in a panic attack
or somatization disorder, such as:•

Headaches•

Abdominal pain•

Fainting spells, lightheadedness, dizziness•Nightmares, sleep difficulties•

Nausea, vomiting•

Cramps, muscle aches•

Palpitations, chest pain.

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IACAPAP Textbook of Child and Adolescent Mental HealthDue to these physical symptoms, SAD is a frequent cause of school
absenteeism and multiple visits to the family doctor or pediatrician to rule out amedical problem. Symptoms only appear on school days and usually disappear assoon as the parents decide the child will stay at home.
Clinical presentation differs according to the patient´s age. Young children
describe having nightmares about separation themes more often than older
children. Also, compared to adolescents, children show more often extreme distressupon separation. They frequently display oppositional behaviors such as tempertantrums in separation situation. Adolescents with SAD have physical complaints
more often on school days. Situations in which separation anxiety symptoms canappear are when the child:• Is left at daycare• Enters school• Gets on the school bus• Is asked to go to bed• Is left at home with baby sitters• Begins summer camp
• Moves households• Stays overnight with friends or relatives• Confronts parental separation or divorce.

Click on the picture to viewa short video on separation
anxiety.

Separation anxiety symptoms appear more frequently in situations such asa change of school, starting a new school term (after summer vacation, or whenstarting high school), changing friends, experiencing adverse events such as beingbullied, or suffering a medical illness.
The boundaries for clinical significance of symptoms vary depending on
cultural factors. Different cultures have different expectations about autonomy,level of supervision, sleeping practices, housing characteristics (e.g., availability ofrooms, size of the house), and the role of parents in child care (e.g., taking care of
the child themselves or leaving the child in daycare) (Hanna et al, 2006).

Marina is a nine year old girl who lives in a large city with her parents and her four year old brother. She is doing 4th
grade at a private school. Since she started kindergarten at the age of two, her teachers noted she was shy and would only
start relating to her class mates by the end of the school year. During the first months of the school year she spent as muchtime as possible with her tutor, even avoiding contact with the rest of the teachers. Transition to pre-school had been difficult
but she managed to make some friends by the last trimester. After that, although she appeared distressed at the beginning ofeach school year, she managed to relate normally to her classmates.
At the age of nine, Marina had the flu, which made her stay in bed for two weeks. When she got better and was allowed
to attend school, she cried impatiently clinging to her mother while begging her not to go. After a few days she managed toreturn to school without excessive crying. However, in the middle of the morning she began complaining of abdominal pain
and had to return home. Her pediatrician found no evidence of abdominal pathology. Another day she felt very tired at school,
dizzy and with headaches. Again, the pediatrician found no evidence of pathology that would explain her symptoms, but her
parents were worried about Marina’s problems and went to see a different doctor who conducted more tests that were all
negative. She never experienced these physical problems on weekends but when Sunday night arrived she became anxious
about presenting the same symptoms at school again on Monday.
Comment: this clinical vignette highlights the symptoms of social anxiety that often precede SAD, the viral infection thattriggers the onset of SAD, the problems with separation and the non-explained medical symptoms upon separation.

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DIAGNOSTIC CRITERIA
Diagnostic criteria for SAD include:•••

Presence of at least 3 out of the 8 possible anxiety symptoms that appear
during separation situations (e.g., separation from home or from major
attachment figures; fear of losing or possible harm befalling to major
attachment figures; reluctance or refusal to go to school, or be alone orwithout major attachment figures, etc.)
Symptoms must be present during at least four weeks, and must start
before the age of 18.
Symptoms cause at least moderate impairment and are not better
explained by another psychiatric disorder.

The main modification proposed for DSM-V is that SAD be moved fromthe category of “disorders usually present in infancy, childhood or adolescent” tothe general category of "anxiety disorders" along with the rest of anxiety disordersthat are diagnosed in children and adults.
In ICD-10, SAD is called “separation anxiety of childhood”. It is included in
the section of “emotional disorders with onset specific to childhood” that includes
phobic anxiety disorder of childhood and social anxiety disorder of childhood,among others.

EPIDEMIOLOGY
Few epidemiological studies have been published and most havemethodological limitations and biases, so data is scarce. SAD has an early age of
onset, the peak onset is between 7 and 9 years of age (Costello & Angold, 1995).
Prevalence is 3%-5% in children and adolescents, and it decreases with increasingage (Costello & Angold, 1995). In the recently published national comorbidity
survey study, Kessler et al (2011) found that anxiety disorders were the mostcommon disorders in all time frames (followed by behavior, mood, and substanceuse disorders), and that SAD was the most common anxiety disorder in children
but the seventh most common lifetime disorder because it often resolves before
adolescence. Sub-threshold SAD is much more common. One study estimatedthat 50% of 8-year-olds suffered SAD symptoms that did not cause significant
impairment. Some investigators suggest SAD in the US may be slightly morecommon in females, African-Americans and families with low socioeconomic
status.
Age of onset and course
Anxiety symptoms upon separation from parents or major attachment
figures are developmentally normal in children (see Chapter A.2). Distress about
separation from attachment figures in infants is one of the most strongly preserved
evolutionary behaviors (Shear et al, 2006). Separation anxiety symptoms usually
peak between nine and 13 months of age, decrease usually after two years ofage, with increasing levels of autonomy by the age of three. Separation anxiety
symptoms may increase again by age four to five, usually when the child starts
school (Costello et al, 2005; Mattis & Pincus, 2004; Krain et al, 2007). The
presence of an anxiety disorder in one of the parents facilitates the persistence of
normal separation anxiety (via genetic transmission and because anxious parents

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may reduce exposure to separations, decreasing the chance of improvement).
Because separation anxiety symptoms are developmentally normative before theage of five, a clinical diagnosis of SAD is rarely justified before then.
Longitudinal studies show that child SAD may be a risk factor for otheranxiety disorders; it specifically increases the risk for panic disorder and agoraphobia
in adults, mainly due to their similar clinical presentation (Biederman et al, 2005).
This is supported by physiological studies, which show an increased sensitivity tocarbon dioxide exposure in children with SAD as well as in patients with panic
disorder (Pine et al, 2000). Other investigators suggest SAD increases vulnerability
for a broad range of anxiety and mood disorders.
Approximately one-third of childhood cases of SAD persist into adulthood
if untreated. A child with SAD may significantly limit his peer interactions, which
could lead to impairment in social functioning or isolation during adulthood (e.g.,remaining single or experiencing marital conflict) (Shear et al, 2006). According
to the Child/Adolescent Anxiety Multimodal Study (CAMS; see treatment section
below) predictors of remission are: younger age, nonminority status, lower baseline
anxiety severity, absence of other internalizing disorders (e.g., anxiety, depression),and absence of social phobia.
The DSM-IV describes SAD as a childhood disorder that seldom persists
into adulthood. However, several studies have found that the prevalence of adult
SAD is around 6%, even higher than childhood SAD. According to one study,
more than 70% of adult cases of SAD started in adulthood; so it might be a much
more common condition than previously recognized (Shear et al., 2006).

ETIOLOGY
The etiology of SAD is complex and partly unknown. Studies demonstratethat both biological and environmental factors play a role, environmental factors
might have a stronger influence in SAD than in other childhood anxiety disorders.
Most proposed etiological factors are associated with anxiety disorders in generalrather than SAD specifically. There is broad agreement that an interaction between
different factors, biological and environmental, increases the risk for anxiety
disorders. For example, the interaction of a mother with low anxiety tolerance anda child with behavioral inhibition is likely to result in anxiety in the child.

•

Prevalence of SAD isapproximately 5% inchildren, decreasing
in adolescence.
Prevalence of adult
SAD is around 6%•

SAD is the mostcommon anxiety
disorder in thepediatric population.

•

Around 50% of eight
year olds sufferedseparation anxiety
symptoms that did
not cause significant
impairment•

Peak onset is
between seven andnine years of age•

Because separation
anxiety isdevelopmentallynormative before
the age of five, adiagnosis of SAD israrely justified before
then•

SAD is a risk factor
for other anxiety andpsychiatric disorders.

•Approximately onethird of childhoodcases of SAD persist
into adulthood if left
untreated.

Biological factors
Genetic
SAD heritability varies from very low to moderate according to different
studies. A large scale twin study suggested a significant genetic influence for SAD,
accounting for a heritability of around 73% (Bolton et al, 2006). Most studies
suggest anxiety disorders run in families (Pine, 1999), and that a person can inherit
vulnerability for any anxiety disorder rather than for a specific anxiety disorder.
Children with anxious parents are five times more likely to present an anxiety
disorder. Some researchers have reported an association between panic disorder inparents and SAD in offspring (Biederman et al, 2004) though this has not been
confirmed.

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PsychologicalPsychobiological processes such as fear conditioning are the underpinningsof anxiety disorders. These are the product of genes and environment on thefunctioning of brain regions involved in fear and reward circuits (amygdala,orbitofrontal cortex, and anterior cingulate cortex).
Dysfunction of some brain areas
The amygdala is one of the main areas implicated in anxiety (Beesdo et al,2009).
Environmental
Many of the environmental risk factors are derived from cross-sectional
epidemiological studies (that can not demonstrate a cause-effect relationship)(Pine & Klein, 2008).
Related to the child´s family
•
•

•

•
•
•
•
•

Low parental warmthParenting behaviors that discourage child autonomy (see Ginsburg
et al, 2004, for a review). Overprotective and over-involved parents
appear to be a specific risk factor for SAD.
Insecure attachment, above all with the mother. An anxious-resistantattachment is associated with anxiety disorders (Warren et al, 1997).
Children of anxious mothers often exhibit anxiety about separation(Beidel et al, 1997; Biederman et al, 2001), not only because children’s
fears about their own security, but also about their mother´s safety
during separation
Severe parental discord
Separation or divorce
Physical illness in a parent
Mental disorder in a parent, such as panic disorder and major depression
Father who is egocentric, immature, instable or with antisocial
behaviors.

Early experiences
•
•
•
•
•

Stressful life events are broadly associated with pediatric psychopathology
in general
Being involved in a major disaster or crime
Exposure to family violence
Parent losing a job
Birth of a siblingChild’s temperament and characteristics•

Behavioral Inhibition reflects a consistent tendency to display fear
and withdrawal in unfamiliar situations which the child tries to avoid.
Behaviorally inhibited children are introverted, easily embarrassed orsocially avoidant. It is usually evident by age two. These children are
more likely than non-inhibited ones to exhibit significant levels ofanxiety of various kinds, including SAD (Kagan et al, 1988; Biederman
et al, 1993; Anthony et al, 2002)

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•
•
•
•

Low tolerance for humiliation
Fear of failure
Depression
Gender. Females have higher rates of almost all anxiety disorders.

Related to the school••

Being bullied
Failure to perform at the expected level in exams, sports or otheracademic activities.

COMORBIDITY
Childhood anxiety disorders are frequently comorbid with each other andwith other forms of psychopathology. Thus it is common that children with SAD
also present with other anxiety disorders or other conditions such as depression
or disruptive behavior disorders (Krain et al, 2007). Compared to children withgeneralized anxiety and social phobia, children with SAD more frequently show
other anxiety disorders, increasing the overall severity (Kendall et al, 2001); suffer
comorbid specific phobias more often (Verduin et al, 2003); and are more likely to
avoid school, resulting in school refusal (futoko in Japan).
Children with SAD more frequently present alos with:•••Major depression (Angold et al, 1999)
Bipolar disorder (Wagner, 2006), andAttention-deficit hyperactivity disorder. Girls with the inattentive
subtype of ADHD may have higher rates of comorbid SAD (Levy etal, 2005).

DIAGNOSISIn DSM-IV and ICD-10, SAD is the only anxiety disorder classified in thesection of "disorders usually diagnosed in infancy, childhood, or adolescence”, andnot included with the other anxiety disorders (although this is likely to change in
DSM-5).
Diagnostic evaluation
School refusal and excessive somatic complaints in the context of actual or
anticipated separations are the most common reasons for parents to seek treatment
for SAD (Krain et al, 2007).
The diagnostic assessment of SAD requires a multi-informant, multimethod approach involving the child, parents and, if appropriate, school teachersor other significant caregivers (see Chapter A.5). The final diagnosis will be basedon information from all these sources. While the gold standard is a structured or asemi-structured clinical interview where children and their parents are interviewed
separately, structured interviews are often impractical in everyday clinical work.
Several semi-structured diagnostic interviews are available:•

The Anxiety Disorder Interview Schedule for DSM-IV Child and Parent
Version (ADIS-IV-C/P; Silverman & Albano, 1996). The ADIS
is designed for youth aged six to 17 years of age; it assesses DSM-

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IV anxiety, mood, externalizing, tic, substance use and pervasive
developmental disorders.
•

The Kiddie Schedule of Affective Disorders and Schizophrenia for School
age children, Present and Lifetime version (K-SADS-PL) is used forpatients six-18 years of age to asses all Axis I diagnosis, except pervasive
developmental disorders.

The majority of childhood anxiety assessment measures are developed for andvalidated with school-aged children, leaving disorders of early childhood relatively
unexplored. The Preschool Age Psychiatric Assessment (PAPA), is a structured parent
interview used to diagnose psychiatric disorders in children aged two to five.
During the interviews, clinicians should assess the three key groups ofanxiety symptoms:•

Behaviors•

Thoughts•

Physical symptoms.

The clinician should explicitly ask about their presence currently and in
the past, timing, frequency, how they interfere with daily functioning, and what
function they may be serving. It is also important to gather information about early
SAD symptoms their development over time, and assess their possible association
with major life transitions or stressors. Anxious children tend to report more physicalsymptoms, while parents usually emphasize the avoidant behaviors. If possible, it is
helpful for the clinician to actually see the patient in a anxiety provoking situation(i.e., entering school). Often children show intense SAD symptoms in the doctor´soffice when they are required to separate from his parents.
As with any other psychiatric disorders, evaluation should include past
psychiatric history, family psychiatric history, medical history and developmental
history (see Chapter A.5).
Somatic symptoms generally have no physical origin. However, a careful
physical examination with appropriate blood work is recommended to ruleout physical causes, including anemia, streptococcal infection (search for antistreptococcal antibodies), hyperthyroidism, hypothyroidism (ask for T3, T4, andTSH), mitral valve prolapse, asthma, gastrointestinal infection, inflammation,
bleeding, or ulceration. Also, urine screening for drugs in adolescents is advisable.
In some cases a clinician can suspect the presence of diabetes mellitus. Rarer
conditions that could mimic SAD symptoms are: babesiosis, Lyme disease, andrickettsial infection. This is important in patients with a history of fever, rash,or sore throat with incomplete or no treatment with antibiotics, and a historyof acute change in personality or anxiety or obsessive symptoms. Blood levels oflead and mercury can be measured to rule out heavy metal poisoning (especiallyin patients with abdominal pain). If other information suggests brain tumor or
seizure disorder, the clinician should perform appropriate imaging studies.

Click on the picture to watch
the video “Understanding
separation anxiety”

As previously mentioned, to meet DSM-IV criteria for SAD, anxiety
symptoms must be beyond what is expected for the child's developmental level,
last longer than four weeks, begin before age 18, and cause significant distressor impairment (APA, 2000). Anxiety has to be exclusively related to separation

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IACAPAP Textbook of Child and Adolescent Mental Healthfrom home or attachment figures, and the patient must have at least three of thefollowing:
•
•
•

•
•
•
•
•

Recurrent excessive distress in separation situations
Persistent and excessive worry about losing, or about possible harm
befalling major attachment figures (e.g., health, accidents, death)
Persistent and excessive worry that an untoward event will lead toseparation from a major attachment figure (e.g., getting lost or being
kidnapped)
Persistent reluctance or refusal to go to school, work, or elsewhere
because of fear of separation
Persistent and excessive fear about or reluctance to be alone or withoutmajor attachment figures
Persistent reluctance or refusal to go to sleep without being near amajor attachment figure or to sleep away from home
Repeated nightmares involving the theme of separation
Repeated complaints of physical symptoms (such as headaches,
stomachaches, nausea, or vomiting) when separation from major
attachment figures occurs or is anticipated.

The current diagnostic criteria have been criticized because examples are
restricted to untoward events happening to the child, but fail to capture untoward
events to attachment figures that may lead to loss, such as worries about death anddying; the need for more studies to test the cut off of four weeks, which is arbitrary.
Rating Scales
Rating scales used in clinical practice or in research are completed by thepatient, parents and or teachers; they provide valuable information to confirm
the diagnosis, quantify the severity of symptoms and monitor treatment response.
However, they should never be used as diagnostic instruments (see Chapter A.5).
Anxiety symptoms in children can be assessed by general psychopathology
rating scales such as the ASEBA instruments (Achenbach, 2009) or specific scales
such as the State-Trait Anxiety Inventory for Children (STAIC; Spielberger, 1973).
The latter is probably more helpful to evaluate separation anxiety symptoms inchildren of all ages. All of the scales mentioned below have shown reasonably good
validity and reliability.
Other widely used rating scales for anxiety symptoms in children andadolescents include the Fear Survey Schedule for Children-Revised (FSSC-R;
Ollendick, 1983), the Revised Child Manifest Anxiety Scale (RCMAS; Reynolds,
1980), the Stait-Trait Anxiety Inventory for Children (STAIC; Papay & Spielberger,1986), and the Social Phobia and Anxiety Inventory for Children (SPAI-C; Beidel
et al, 2000).
Differential diagnosis
Anxiety symptoms can be the manifestation of:••Normal developmental anxiety (e.g., normal fears during the first few
days of school), in this case symptoms would be self-limiting
Medical illness (e.g., hyperthyroidism, Cushing syndrome, brain
tumor). Symptoms would not be restricted to situations involving

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ClinicianChild,
ParentParentPARS(Research Units on Pediatric
Psychopharmacology Anxiety
Study Group, 2002)

RCADS(Chorpita et al, 2000)

The Preschool Anxiety Scale(Spence et al, 2001)*Non-proprietary: free for clinical use.



Child
(parent
version)

SCARED-R(Muris et al, 1998)

2-6

6-18

7-18



Child,
ParentSAAS-C/P(Eisen & Schaefer, 2007)



8-12

Child,(Parent
version)SCAS(Spence, 1997)

SAD
subscale

Patient´s
age

Rater

Scale

Recommended
for screening

Table F.2.1 Scales* to rate separation anxiety symptoms

34 items, some specific of SAD
4 dimensions: fear of being alone, fear of abandonment, fear of physicalillness, and worry about calamitous events.
Also contains a “frequency of calamitous events subscale” and “safety
signals index”.
Total of 66 items including all DSM-IV anxiety disorders, 8-items
specifically assess SAD.
Available in 8 languages•••

47 items, self-report questionnaire.
Includes all anxiety disorders and major depression
It yields a total anxiety score and a total internalizing score. There is alsoa parent version.
Available in 5 languages.
Parent self-report.
A preschool version of the SCAS.

•
•
•

•
•

•

Requires interviews with parents and child

•

•

•

•
•

44 items, uses a 4-point scale
6 subscales: separation anxiety, panic/agoraphobia, social anxiety,generalized anxiety, obsessions/compulsions, and fear of physical injury
Preschool scale for 2.5-6.5 years of age
Available in 16 languages••

Comments

IACAPAP Textbook of Child and Adolescent Mental Health10IACAPAP Textbook of Child and Adolescent Mental Healthseparation from attachment figures and the child would present othermedical signs, such as vision or coordination impairment in the caseof brain tumors•

Anxiety disorders different from SAD, such as generalized anxiety
or social phobia (worries about "everything" or social situations,
respectively, not fear about separation specifically), and the presenceof an attachment figure does not alleviate symptoms (see Chapter F.1)•

Other psychiatric disorders such as depression•

In adolescents, alcohol and substance use such as cannabis, cocaine orcaffeine. Symptoms would occur when under the effect of the substanceor upon withdrawal•

Adverse environmental circumstances such as inappropriate academic
placement, fear of violence at school (e.g., gang-related violence), beingbullied, grief reaction. Symptoms would typically start acutely andworsen when exposed to these situations.

•

Truancy. The adolescent would deliberately not attend school.

Clinicians may recommend
books or websites to obtain
more information, forexample:TREATMENT
There are multiple treatment options for children and adolescents sufferingfrom SAD. The clinician should select the most appropriate therapeutic option
for each specific patient after considering factors related to the disorder (severity,
duration, dysfunction due to symptoms), the patient and his family (chronologicaland developmental age, insight, treatment preferences, family motivation andavailability, financial resources), and the clinician (availability, skills and experience).
Most data about effectiveness of treatment refer to non-pharmacologicaltreatments: psychoeducation, behavioral management and different forms of
cognitive behavioral therapy. Thus, these should be the clinician´s first choice.
Psychoeducation
In all cases, it is essential to build a good therapeutic alliance between thepatient (and family) and the clinician. This is best developed in the context of
psychoeducation, which is also fundamental in all treatment processes. Educating
the family and the child (according to their developmental age), increases insightand motivation. Understanding the nature of anxiety and how it is experienced by
the child will help parents and teachers sympathize with a child's struggles.
Psychoeducation should always cover:•Anxiety as a normal emotion, at all developmental stages•

Factors that may cause, trigger or maintain anxiety symptoms•

The natural course of SAD•

Treatment alternatives, including their advantages and disadvantages•

Prognosis

There is a multitude of books and much (good and bad) information in theInternet about anxiety disorders. Some of the most useful can be found in sideboxes.

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IACAPAP Textbook of Child and Adolescent Mental HealthBehavioral management
Behavioral management is indicated in all cases. It consists of informing
family members and significant caregivers, how to manage mild symptoms andmaladaptive attitudes such as avoidant behaviors or cognitive biases. It may be theonly treatment required in cases of mild separation anxiety (which generally occur
during pre-school). This should be combined with other therapies if there is no
improvement or symptoms are moderately severe, or cause moderate dysfunction
or distress. The main objective of behavioral management is to provide the child aflexible and supportive environment to overcome his separation anxiety symptoms.
The clinician may recommend parents to:
•
•
•
•

•
•
•

Listen to the child's feelings empathically
Keep calm when the child becomes anxious (to model the child’s
behavior)
Remind the child that he had survived similar anxious situations before
Teach simple relaxation techniques such as deep breathing, counting to
10, or visualizing a relaxing scene. Learning how to relax gives the childa sense of control over his body
Plan transitions, such as getting to school in the morning or preparing
for bed at night
Help the child prepare a list of possible strategies in case anxiety appears
in "difficult" situations
Support the child's prompt return to school (long absences make returnto school more difficult)Interventions at home
A parent may read a specialized book with the anxious child, while reassuring that it is fine for the child to feel that way andthat nothing will happen. There are many books for this purpose, such as "The good-bye book" by Judith Viorst; "The Kissing
Hand" by Audrey Penn; "Even if I Spill My Milk" by Anna Grossnickle Hines; "Benjamin Comes Back" by Amy Brandt; "When
Mama comes home" by Eileen Spinelli; "The invisible string" by Patrice Karst.

When symptoms of
separation anxiety result in
the child rejecting school,a parent can share books
that specifically discuss
this such as: "I don´t Want
to Go to School" by Nancy
Pando.

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IACAPAP Textbook of Child and Adolescent Mental Health•••

Encourage the child's participation in activities outside the home,
without attachment figures (promote exposure). Do not let him stay athome to avoid distress (do not allow avoidance)
Praise the child's efforts (not only his results) to address symptoms(reinforce repeatedly during his way to success)
Assure the child/adolescent that somatic symptoms are indicators of aproblem that requires attention, just not a physical problem.

Interventions at school
The clinician can recommend teachers to:
•
•
•
•
•
•
•
•
•
•
•

•
•

Initiate a plan to promote the child´s return to school as soon as possible
Maintain frequent meetings with parents to facilitate collaboration in
strategies to help the child normalize schooling
Assess the cause of the child's school refusal and address it (e.g.,
problems with friends, fear of a teacher)Supervise the child´s arrival to school, preferably the same person every
time
Allow an attachment figure to initially accompany the child
Allow a shorter school day and lengthen it graduallyIdentify a safe place where the child can go to reduce anxiety during
stressful periods
Identify a safe adult to whom the child can ask for comfort at all times,
most of all during stressful periods
Promote practicing relaxation techniques developed at home
Provide alternative activities to distract the child from physicalsymptoms
Encourage small group interactions. This can start with only one
classmate. With time, the child will increase his competency and thegroup may be enlarged progressively. Provide assistance with these peerinteractions.
Reward a child's efforts
Allow extra time for transitioning to different activities.

Cognitive Behavior Therapy (CBT)Several randomized controlled studies have shown the short and long term
effectiveness of CBT in ameliorating childhood anxiety disorders, including SAD.
CBT is currently the treatment with the most evidence supporting its efficacy(Barrett et al, 1996; Kendall et al, 1997). Thus, CBT has become the initial
treatment of choice. The exception is when anxiety symptoms are too severe toallow working with the child in therapy. In that case, medication or both treatments
concurrently would be indicated.
There are several manualized CBT programs, mostly based on classicaland operant principles and social learning. The duration of CBT depends on theseverity, treatment design and patient´s response.
The targets of CBT are to:••Gain insight about the presence and the origin of anxiety symptoms
Control worries

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IACAPAP Textbook of Child and Adolescent Mental Health••

Reduce arousal
Confront the feared situations.

To achieve those objectives, CBT usually includes the following:
•
•
•
•
•
•
•

Psychoeducation
Cognitive restructuring (reducing negative self-talk and addressing
negative thoughts, among other strategies)
Improving problem solving skills
Relaxation training (to address physical symptoms)
Modeling
Contingency management
Exposure and response prevention.

Exposure and response prevention are the key element of CBT for anxiety
disorders, which is included in all programs in different forms. First the childis helped to list the top anxiety-provoking situations. This serves as an initialdescription of the symptoms, and will be used later as a measure of treatment
progress. The child rates each situation for level of fear and degree of avoidance, on
a 0 (not at all) to 10 (extreme) Likert scale (specifically designed for the child’sdevelopmental stage or cognitive level such as a “fear thermometer”). Some
programs only grade the level of fear/anxiety, but the inclusion of an avoidance
rating may help in designing exposure experiences. Therapist and parents may
assist in performing the rating.
As explained, there are many CBT programs. Here, we mention two of
them: The Coping Cat and the Friends programs.
The Coping Cat program
The Coping Cat (Kendall , 2000) is a manualized, proprietary intervention
for youth with anxiety disorders, including SAD. The program incorporates
cognitive restructuring and relaxation training followed by gradual exposure toanxiety-provoking situations applying learned coping skills. It has been shown to beeffective in SAD (and also in generalized anxiety and social phobia). Randomized
clinical trials have achieved remission rates as high as 66% (Kendall et al, 1997).
Follow-up assessments at three and 7.5 years showed that treatment gains weremaintained over time (Kendall & Southam-Gerow, 1996; Kendall et al, 2004).
The “Friends” program
The Friends program is a 10-session CBT intervention delivered in a groupformat for children with anxiety disorders, with two levels: treatment and universal
preventive intervention. FRIENDS is the acronym for: F—Feeling worried?; R—
Relax and feel good; I—Inner thoughts; E—Explore plans, N—Nice work so
reward yourself; D—Don’t forget to practice; and S—Stay calm, you know how tocope now. The program has all the essentials of CBT programs including cognitive
restructuring for parents. Also, parents are encouraged to practice the skills daily
and are given positive reinforcement for doing so. The program encourages families
to develop supportive social networks, and children to develop friendships amonggroup members by talking about difficult situations and learning from peers’
experiences. It also incorporates some elements of interpersonal therapy. Shortt etal (2001) conducted a RCT applying the Friends program in children 6-10 years

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IACAPAP Textbook of Child and Adolescent Mental Healthold, with SAD, generalized anxiety or social phobia, obtaining remission rates of
69%. Therapeutic gains were maintained one year later.
Camp-like CBTCamp-like CBT is an intensive intervention for school-age girls with SAD
delivered in the context of a one-week camp-like setting. A potential benefit ofa camp-based group approach for SAD is the incorporation of children’s social
context into treatment (away from parents), thus allowing a more naturalistic
exposure regarding typical separation situations, such as group field trips, activities
and sleepovers. The program also includes parents, whom clinicians educate on the
management of SAD symptoms. A RCT suggested significant reductions in SAD
severity and treatment gains (Ehrenreich et al, 2008).
The role of the family in CBTFamily involvement is essential because parents often play a role in themaintenance of children’s separation fears and should support the treatment planby consistently applying the behavioral management at home. Some programs,
also CBT based, emphasize family involvement, such as Parent-Child Interaction
Therapy (PCIT).
Parent-Child Interaction Therapy (Brinkmeyer & Eyberg, 2003) has been
adapted for children aged four to eight with SAD (Choate et al, 2005; Pincus etal, 2005) but requires considerable resources often not available in many services,even in high income countries. PCIT has three stages:•••

Child-directed interaction: teaches parents to be warm and praiseful, topromote the child’s feeling of security in order to facilitate separationfrom the parent
Bravery-directed interaction: the therapist works with both the parents
and the child to develop a list of situations the child is fearful of or
currently avoiding, in order of severity. The family creates a reward list
to reinforce the child’s efforts.
Parent-directed interaction: parents learn how to manage the child´smisbehavior based on operant principles of behavior change (such as
consistent positive and negative consequences). Also, parents learn not
to reinforce the child´s anxious behaviors, for example not giving thechild more attention when he skips class (Eisen et al, 1998).

During all three stages, parents are actively coached on how to apply theskills. Coaching may take place through a one-way mirror, using walkie-talkies oran ear-piece microphone. Mastery is measured by the number of times the parents
use a specific skill. Preliminary analyses in as yet unpublished controlled trial toassess the efficacy of PCIT in children with SAD suggest a clinically significant
improvement, with continued improvement over time.
CBT for pre-schoolers
Most CBT programs are designed for children aged six years or older.
Hirshfeld-Becker et al (2010) examined the efficacy of a developmentally
appropriate parent-child CBT program for anxiety disorders in children aged fourto seven. The response rate was 69% (versus 32% in controls) and gains weremaintained at one year follow-up.

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Also available for preschoolers is the CALM program (Comer et al, 2012),
a form of parent-child interaction therapy, for children aged three to eight with
SAD, social anxiety disorder, generalized anxiety, or specific phobias. A controlled
trial has shown promising results of live parent coaching in this population (Comeret al, 2012).
Pharmacological treatment
Medication should always be used in addition to behavioral or
psychotherapeutic intervention. Medication is not generally recommended as afirst line treatment for SAD. However, it is a useful strategy when CBT achieves
no response or partial response, or when the child is significantly impaired. No
medication has been specifically approved for SAD. However, various medications
have been investigated for childhood anxiety disorders, such as selective serotonin
reuptake inhibitors (SSRIs), tryciclic antidepressants (TCAs), benzodiazepines,
buspirone, serotonin and noradrenaline reuptake inhibitors (SNRI), propanolol,
clonidine, atypical antipsychotics, antihistamines and melatonin. All medications
should be started, stopped or adjusted under the supervision of a trained clinician.
SSRIs
There are numerous RCTs assessing the efficacy of SSRIs in children andadolescents with SAD, generalized anxiety and social phobia (Reinblatt & Riddle,2007). In those studies SSRIs have proved to be effective and have a favorable
adverse effect profile. Thus, they are considered the first choice medication inanxiety disorders, including SAD (Reinblatt & Riddle, 2007). In fact, SSRIs
may be more effective in anxiety disorders than in major depression (Bridge etal, 2007). In spite of the clinical evidence, no SSRI has been approved by the US
Food and Drug Administration (FDA) for the treatment of anxiety disorders inchildren and adolescents. Thus, when clinicians prescribe an SSRI to a patientunder 18 years old with SAD, they are doing so "off-label" in the US – thesituation may be different in other countries (several SSRIs are approved for thetreatment of obsessive compulsive disorder, see Table F.2.2). In June 2003 the
FDA recommended that paroxetine not be used in children and adolescents withdepression. The other SSRIs appear to be of similar effectiveness.
Different controlled trials have investigated different SSRIs: fluvoxamine(e.g., Research Units on Pediatric Psychopharmacology Anxiety Study Group,2001); fluoxetine (e.g., Birmaher et al, 2003); sertraline (e.g., Walkup et al, 2008).
However, there are no studies assessing the long term effectiveness in pediatricpopulations with SAD.
Table F.2.2
US Food and Drug Administration approved SSRIs forchildren and adolescents
SSRI

Indication

Patient´s age

Escitalopram

Depression

12-17

Fluoxetine

Depression

8-17

Fluoxetine

OCD

7-17

Fluvoxamine

OCD

8-17

Sertraline

OCD

6-17

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Table F.2.3

Summary of the characteristics of commonly used SSRIs

SSRI

Initial dose
(mg/day)

Target dose
(mg/day)

Citalopram

5

10-40

Escitalopram

5

10-30

Fluoxetine

5

10-80

Fluvoxamine

1050-300Paroxetine

Sertraline

5

10-60

25

50-200Comments••

Long half life
Can decrease appetite andsexual function•••

Very short half life
Less effective in children (FDA
discourages its use)
Frequent side effects••

Few interactions
Few side effects

The Child/Adolescent Anxiety Multimodal Study (CAMS), one of themost comprehensive trials of anxiety disorders in youngsters is a good exampleof the studies available. This multisite trial included 488 children and adolescents(ages 7-17 years) with SAD, generalized anxiety or social phobia. Patients wererandomized to 12-week treatment in one of these four arms: (a) sertraline, (b)cognitive behavioral therapy (CBT), (c) a combination of sertraline and CBT, and(d) clinical management with pill placebo. After 12 weeks of treatment all active
therapies were superior to placebo. Remission rates (that is, achieving a nearly
symptom-free state) were highest for the combined group (46% to 68%), followed
by sertraline (34% to 46%), followed by CBT (20% to 46%), and lastly for placebo(15% to 27%). Rates of response (i.e., a clinically significant improvement) weresignificantly higher than rates of remission. The main conclusion was that CBT
alone and sertraline alone were effective short term treatments but there was a clear
advantage in combining both (Walkup et al, 2008).
Practical issues about prescribing SSRIs in children and adolescents
Prescribers should start with a low dose and titrate it weekly, monitoringclinical response and side effects. To achieve maximum benefit children may needas high a dose as adults. Table F2.3 presents initial and target doses. SSRIs can beadministered daily in the morning. Evening dosing is possible if treatment does
not disrupt sleep. SSRIs usually begin to be effective in two to four weeks. Up
to 12 weeks may be required to determine whether the medication is effective
for a specific patient. It can take up to 16 weeks to achieve significant clinicalimprovement. However, if a patient does not show any benefit by week eight, adifferent SSRI should be tried. Even when patients improve they frequently remain
symptomatic. In that case, the clinician should assess the need to increase thedose if the patient tolerates it well. Most studies report additional benefit accruing
over 6-12 months (Connolly et al, 2007). Thus, it is recommend continuing
treatment at least for one year after achieving full remission. However, there is no
specific evidence supporting this recommendation. Advantages of maintaining

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IACAPAP Textbook of Child and Adolescent Mental Healthpharmacotherapy include:• Helping the child consolidate behavioral gains• Increasing the synergistic effect of combination therapy (SSRI + CBT)• Reducing the probability of relapse.
Deciding when to stop treatment may be difficult. It is not advisable todiscontinue medication at the start of a new school year, while at camp, during
final exams, or even during vacations. A discontinuation trial is advisable when
the patient can be monitored closely and is in a stable environment at school andat home, that is, not in a novel situation. As with all medications, dose should
be tapered progressively, avoiding abrupt discontinuation to prevent withdrawal
effects. It is also important not to mistake withdrawal symptoms for a recurrenceof the illness. If symptoms return, medication should be restarted back to the dosethat resulted in remission.
Patients usually tolerate SSRIs well. Common side effects include: drowsiness,
abdominal pain/discomfort, headaches, and feelings of restlessness. Apathy can be
Table F.2.4
Second line medications* for anxiety disorders inchildren and adolescents
Medication

Possible indication

Comments

SNRIs:(e.g., venlafaxine
duloxetine)

•

•

TCAs:
(e.g., imipramine,clomipramine)•

Benzodiazepines:(e.g., clonazempam,
clorazepate)•

Buspirone

Refractory to SSRIs
and CBT•
Refractory to SSRIs
and CBT•••No compelling evidenceof effectiveness in anxiety
disordersMore side effects than SSRIs
More side effects than SSRIs
Requires baseline andperiodic ECG monitoring
Potentially lethal in overdose

Short term
treatment of acuteanxiety (rapid
solution needed)••

Refractory to SSRIs
and CBT•

Effectiveness notdemonstrated in children

Propranolol•

Intense autonomic
response•

Should not be usedby asthmatics or withantihypertensive agents

Clonidine••

Intense autonomic
response
Comorbid PTSD
or acute stress
reactions•••

More side effects than SSRIs
Potentially lethal in overdose
Requires baseline andperiodic ECG and bloodpressure monitoring

Antihistamines•

Insomnia•

Can provoke somnolence,increased appetite

Melatonin•

Insomnia•

Unknown long term side
effects•

Potential abuse anddependence
Risk of paradoxical reaction
in children*None of these medications are FDA approved for the treatment of anxiety disorders inchildren.

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IACAPAP Textbook of Child and Adolescent Mental Healtha late-onset side effect and it is less known because it is infrequent. Clinicians often
misinterpret it as a symptom. Side effects, when present, are generally mild andusually dissipate after the first days or weeks of treatment. If these are marked or
persistent the clinician should lower the dose. If they persist, the clinician should
discontinue the medication and try another SSRI. There are anecdotal cases of newonset easy bleeding or bruising. In most cases coagulation tests and bleeding times
are either delayed or normal. Rarely, a patient may suffer a (hypo)manic switch
or episode, characterized by changes in mood (elevated, euphoric or irritable) or
behavior (grandiosity, fast speech, higher level of energy and activity), and possible
psychotic symptoms (See Chapter E.2). Should this occur the medication must
be discontinued and the clinician should assess a diagnosis of bipolar disorder. As
is the case with depression, suicide risk should be monitored closely, particularly
early during treatment. There is no need to routinely run laboratory testing or
ECG at baseline or during follow-up, if the patient is asymptomatic.
Second line medications for SAD
Some patients do not tolerate SSRIs or do not show (sufficient) clinical responsewith them. In those cases, a clinician can indicate second line medications. These
are listed in Table F.2.4.

SPECIFIC CROSS-CULTURAL SYNDROMES RELATEDTO SEPARATION ANXIETY DISORDER
tokokyohi (school refusal) and futoko (school non-attendance)
Broadwin introduced the concept of “school refusal” in 1932, although heused the term “truancy”. Until then, truancy referred to school non-attendanceassociated with antisocial behavior, Broadwin being the first to use the term todescribe non-delinquent school absenteeism. In 1941 Johnson used the term “school
phobia” to refer to long-term school absenteeism attributed to separation anxiety.
Subsequently, experts described other causes for long term school absenteeism
different from SAD. In 1948 Warren described this situation as “refusal to go toschool”; since then, it was commonly designated “school refusal” (Hersov, 1960).
In Japan, the concept of school phobia was introduced in the latter half of the
1950s. In the 1960s it was called “school refusal” (toko kyohi in Japanese). In the
1990s, experts used the term school non-attendance (futoko in Japanese). However
both concepts are very similar and toko kyohi and futoko virtually describe thesame symptoms, so we will use the term “school refusal” to refer to both, unlessotherwise specified.
Berg (1980) defined “school refusal” as:1. Severe difficulty attending school usually amounting to prolonged
absenteeism.
2. Severe emotional distress when going to school, or anticipating
the idea of going. Symptoms include excessive fearfulness, tempertantrums, feelings of misery, and physical complaints without anobjective organic cause.
3. Staying at home in school hours, with parental knowledge.
4. Absence of significant anti-social behavior such as stealing, lying,running away, and destroying property.

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IACAPAP Textbook of Child and Adolescent Mental HealthJapanese school children withbackpacks, Fukuoka, Japan
Photo: Blog of Andy HoboTraveler.
com

Characteristics 2, 3 and 4 clearly distinguished the novel concept of“school refusal” from “truancy” and considered it a distinct disorder. Atkinson
and Quarrington (1985) argued that School refusal should not be considered amental disorder but a symptom or a socio-psychological phenomenon. Therefore
they proposed that school refusal should be understood as “long-term absenteeism
characterized by the presence of fear, rejection, or anger vis-à-vis participation in school,combined with a strong sense of guilt concerning absenteeism itself, and concomitant
conflict with life withdrawn into the home” (Atkinson & Quarrington, 1985).
Unlike SAD, school refusal is not a DSM diagnosis. In the past school
refusal was often used interchangeably with school phobia. We know now that not
all children who refuse to go to school suffer from SAD. However, in young
children the most frequent cause of school refusal is SAD, and should always be
ruled-out. In 10 to 15 year olds, school refusal is generally due to generalized
anxiety or social phobia (for a description of these disorders see Chapter F.1).
In adolescents with school refusal an underlying panic disorder may be present,
but also depression, obsessive-compulsive disorder, or somatoform disorder. Other
reasons for adolescents refusing to go to school are violence in the home andexcessive use of internet combined with social phobia / withdrawal (hikikomori).
Unlike younger children, during early adolescence SAD is less often the cause

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IACAPAP Textbook of Child and Adolescent Mental Healthand school refusal often leads to long-term absenteeism. However, it is possiblethat school refusal is not accompanied by any psychiatric disorder; the etiology ofschool refusal can be very heterogeneous (Egger et al, 2003). Kearney and Albano(2004) conducted a study with 143 youth aged 5-17 with primary school refusal.
Up to 22% had SAD, the most frequent psychiatric diagnosis, but 33% did nothave any psychiatric diagnosis.
Recent reviews suggest a prevalence of school refusal between 1% and
5% in non-clinic referred and clinic-referred children, respectively. Peak onset
occurs when at 5 to 6 and 10 to 11 years of age, coinciding with the transition tokindergarten and middle school respectively. Other high risk times for the onsetof school refusal are moving to a different community or to a new school and after
major social events or holidays.
Approximately 25% of cases of school refusal remit spontaneously or are
successfully dealt with exclusively by parents. In adolescents, referral can be delayed
because somatic complaints may not coincide exactly with separation situations(unlike in younger children), thus hindering diagnosis.
Longitudinal studies indicate that school refusal can lead to serious shortterm problems such as academic decline, alienation from peers and family conflict(Kearney & Bensaheb, 2006) and long term consequences such as increased risk ofpsychiatric disorders and social and employment difficulties. Saito (2000) reported
the results of a 10 year follow-up of 106 students who had been hospitalized fortreatment of school refusal after graduating from a junior high school. By their
mid-twenties, 73% were socially well adjusted while 27% were not. Further, halfof the latter also showed social withdrawal (hikikomori).
KEY POINTS
•
•
•
•
•
•
•
•
•
•
•
•

SAD is the most common childhood anxiety disorder, with a prevalence of around 5%
in children, and it is associated with high levels of impairment.
The key symptom of SAD is inappropriate distress or excessive and unrealistic fear
upon separation from attachment figures or the home
SAD is the most frequent cause of school refusal in young children, while generalized
anxiety and social phobia are more often the cause in older youth
Etiology of SAD includes biological and environmental factors
Frequently children with SAD also suffer from other anxiety disorders or otherpsychiatric disorders such as depression or disruptive behavior disorders
There are multiple, effective treatment options available.
Psychoeducation and behavioral management should always be the starting point.
CBT is the initial treatment of choice when children do not improve withpsychoeducation and behavioral management
Medication is indicated when CBT achieves no response or partial response, or when
the child is significantly impaired. Medication and CBT should always be used inaddition to psychoeducation and behavioral management
The most effective treatment is the combination of CBT and medication
Currently, no medication is approved by the FDA for children and adolescents withSAD (this may not be the case in other countries). However, clinicians often use
SSRIs, which have been shown to effective and well tolerated
If left untreated, SAD is associated with elevated risk for other internalizing disorders
as well as impairments in educational attainment and social functioning.

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