Separation anxiety disorder

Diagnosis

• Developmentally inappropriate/excessive fear or anxiety concerning separation  from home or from major attachment figures.:
  • Recurrent excessive distress when anticipating or experiencing separation
  • Persistent and excessive worry
    • losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death.
    • experiencing an untoward event (e.g. – getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.
    • being alone or without major attachment figures at home or in other settings.
  • Persistent reluctance or refusal
    • to go out
    • away from home
    • to school
    • because of fear of separation.
    • to sleep away from home/to go to sleep without being near a major attachment figure.
  • Repeated nightmares involving the theme of separation.
  • Repeated complaints of physical symptoms
    • Headaches
    • Stomachache
    •  Nausea
    • Vomiting

when separation from major attachment figures occurs or is anticipated.

Time

• For more than 4 weeks in children 
• adolescents and typically for more than 6 months or more in adults

disturbance causes 

• clinically significant distress
• impairment in social, academic, occupational, or other important areas of functioning

Epidemiology

• 4% of children
• It is equally common between males and females

Prognosis

• Start at preschool age and can occur at any time during childhood and more rarely in adolescence.
• Symptoms can wax or wane over the course of the disorder.
• do not have impairing anxiety over the course of their lifetimes, and many as adults do not recall their history of anxiety.
• Separation anxiety is actually a protective factor against substance use.

Comorbidity

• Separation anxiety in childhood increases the risk for developing
  • panic disorder
  • followed by major depressive disorder.
• In children, separation anxiety disorder is highly comorbid with
  • generalized anxiety disorder
  • specific phobia.

Risk Factors

• major life stressors
  • death of a relative or a pet
  • illness of a loved one, parental divorce, change of schools, immigration, and disasters that involve separation.[7]
• Parental overprotection and intrusiveness

Treatment

• Psychotherapy
  • Separation anxiety disorder responds well to cognitive behavioural therapy
  • Cognitive-Behavioral Therapy (CBT):
    • Exposure Therapy: Gradual and systematic exposure to separation triggers can help reduce anxiety over time.
    • Cognitive Restructuring: Identifying and challenging negative thoughts associated with separation to develop more realistic and adaptive beliefs.
  • Parent-Child Interaction Therapy (PCIT):
    • In cases involving children, PCIT involves both the child and the parent. It helps improve the parent-child relationship and addresses separation anxiety through specific techniques.
  • Family Therapy:
    • In cases where family dynamics contribute to the anxiety, family therapy can be beneficial. It helps improve communication and understanding among family members.
  • Gradual Desensitization:
    • Gradually exposing the individual to situations that trigger anxiety, starting with less anxiety-provoking scenarios and progressing to more challenging ones.
  • Create Predictability:
    • Establishing consistent routines and schedules can provide a sense of predictability and security for individuals with separation anxiety.
  • Promote Independence:
    • Encourage and support the development of age-appropriate independence. This can include simple tasks like getting dressed or completing homework on their own.
  • Positive Reinforcement:
    • Use positive reinforcement strategies to reward and encourage behaviors that demonstrate increased independence and coping with separation.
  • Social Skills Training:
    • Develop and enhance social skills to improve the individual’s ability to connect with others and build relationships.
  • Relaxation Techniques:
    • Teach and practice relaxation techniques such as deep breathing, meditation, or progressive muscle relaxation to manage anxiety.
  • Secure Base Concept:
    • Encourage the individual to identify and internalize a “secure base” – a person or place that provides comfort and safety.
  • School-Based Interventions:
    • Work with school staff to create a supportive environment, including a trusted adult the child can turn to when needed.
  • Parental Involvement:
    • Involve parents in the therapeutic process, educating them on how to support their child while gradually promoting independence
• Pharmacological
  • Psychological therapies are always preferred over pharmacotherapy.
  • Generally speaking, selective serotonin reuptake inhibitors and tricyclic antidepressants are the most commonly studied medications for anxiety disorders in children.
  • Fluoxetine, fluvoxamine, and sertraline have been studied.
  • Benzodiazepines should never be used (no better than placebo)