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Introduction

Separation anxiety is a normal phase of child development, beginning in the first year of life (6-12 mo) and peaking around 18 months.

  • Separation anxiety that persists past 6 years of age, is generally pathological, or generally signifies a separation anxiety disorder
  • Separation anxiety is distinct from the phenomenon of "stranger anxiety" which peaks in the first year of life, and generally resolves by 24 months.

Epidemiology

Children have a 12-month prevalence of 4%
Adolescents have a 12-month prevalence of 1.4%
DSM-5 recognized that separation anxiety disorder occurs in adults, with estimated 12-mo prevalence of 0.9-1.9%. The evidence is substantial and is summarized by Bogels. (4)
Heritability is estimated at 73%, suggesting appreciable genetic contribution to the disorder. (DSM-5)

Diagnosis

Separation anxiety disorders often develop after a loss of a family member, friend, or a pet; it may also be triggered by illness in the family, parental separation, and natural disasters.

The core feature of SAD is excessive fear or anxiety with sepration from home or from attachment figures.

  • in younger children this may manifest as school refusal, difficulty sleeping alone or at friend's house, "clingy" behaviors, tantrums, and nightime illusions and hallucinations.
  • in pre-teens and adolescents, fears about kidnapping of parent, sickness, or accidents emerge.
  • in adults, "home sickness" may be reported as a significant symtpoms, as well as overall difficulty with life transitions (moving to college, getting married). (DSM-5)

DSM changes

DSM-IV classified sepration anxiety under the Disorders of Infancy, Childhood, or Adolescence.

  • criteria call for 1mo of dysfunction beginning before age 18 years.

DSM-5 puts it under the umbrella of Anxiety Disorders, and relatedly eliminated the requirement for presence of symtpoms/dysfunction before 18.

  • adults can be diagnosed with separation anxiety disorders if the symtpoms persist for at least 6 months.

Comorbidities

co-occurring anxiety disorders, such as generalized anxiety disorder and social anxiety disorder, are the rule rather than the exception

Treatment

Medications

There are no FDA-approved medications for separation anxiety disorder, but evidence for efficasy and safety of SSRI's is considerable. Separation anxiety disorder is often lumped in studies with co-occuring anxiety disorders.

In the Child/Adolescent Anxiety Multimodal Study (CAMS) (1), sertraline (up to 200 mg/day), pill placebo, CBT, and their combination were compared over 12 weeks in 488 children ages 7–17 years presenting with separation, generalized, and/or social anxiety disorder.

  • Combination treatment was superior to CBT alone and sertraline alone (p<0.001, effect size=0.86).
  • CBT alone (effect size=0.31) and sertraline alone (effect size=0.45) were equally effective, and all active treatments were superior to placebo (p<0.001).

There is also evidence from placebo-controlled trials for treatment of anxiety with fluvoxamine (up to 300 mg/day) (2), and fluoxetine (20mg/day) (3).

Some effort had been made to study tricyclics specifically for school refusal and separation anxiety. This yielded several positive and several negative trials for imipramine and clomipramine. (3)

Psychosocial interventions

Psychosocial interventions should involve CBT and family education, including understanding the positive and negative reinforcement patterns that often maintain a child’s anxiety symptoms and impairing behaviors. (3)

References

1. Walkup JT; Albano AM; Piacentini J; Birmaher B; Compton SN; Sherrill JT; Ginsburg GS; Rynn MA; McCracken J; Waslick B; Iyengar S; March JS; Kendall PC: Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med 2008; 359:2753–2766

2. Research Unit on Pediatric Psychopharmacology Anxiety Study Group: Fluvoxamine for the treatment of anxiety disorders in children and adolescents. N Engl J Med 2001; 344:1279–1285

3. Mohatt J, Bennett SM, Walkup JT. Treatment of separation, generalized, and social anxiety disorders in youths.Am J Psychiatry. 2014 Jul 1;171(7):741-8. doi: 10.1176/appi.ajp.2014.13101337.

4. Bögels SM, Knappe S, Clark LA. Adult separation anxiety disorder in DSM-5. Clin Psychol Rev. 2013 Jul;33(5):663-74. doi: 10.1016/j.cpr.2013.03.006. Epub 2013 Apr 2.

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