Beyond Normal Attachment: Managing Childhood Separation Anxiety Disorder

Separation anxiety disorder (SAD) is characterized “by an abnormal reactivity to real or imagined separation from attachment figures, which significantly interferes with daily activities and developmental tasks.”¹ Originally diagnosed only in children, the current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, allows SAD to also be diagnosed in adults.² Diagnostic criteria for SAD in children are listed in Table 1.

SAD has a prevalence of roughly 4% to 5% in children and adolescents, with 50% to 75% of affected children coming from homes of low socioeconomic status.¹ It is almost twice as common in girls as in boys.³

Generalized anxiety disorder (GAD), SAD, and social phobia are among the most common childhood psychiatric disorders and carry substantial risk for depression, anxiety, and impaired quality of life throughout the patient’s life.⁴ These childhood disorders are highly comorbid with one another, although GAD tends to have high rates of comorbidity with other conditions.²

“In very early childhood, separation concerns are typical, expected, and age-appropriate,” according to Wendy Silverman, PhD, ABPP, Alfred A. Messer Professor in the Child Study Center and Director, Anxiety and Mood Disorders Program, Yale Child Study Center, New Haven, Connecticut.

“It becomes a disorder when it becomes impairing and interferes with the child’s ability to reach developmental benchmarks and participate in ordinary childhood activities, and when a child is experiencing extreme distress, due to concerns about being away from the parent or caretaker,” she told Psychiatry Advisor.

Dr Silverman provided several examples. “A lot of these children — we’re talking about ages 8 or 10 and even in the teenaged years — have never been able to sleep alone in a bed without the parent present, or attend events with children their own age, such as parties, or after-school activities such as sports, or ballet class, without the parent being there.”

And similar to other anxiety disorders, “separation anxiety is multidetermined and is caused by a host of factors, including genetic, parenting, temperament, modeling, and social learning,” she observed.

Etiology and Mechanisms of SAD

Although there are no definitive answers regarding the cause of SAD, there are some hypotheses. The Anxiety and Mood Disorders Program at Yale has been at the forefront in publishing scientific studies that suggest the neuropeptide oxytocin may be impaired in children with SAD and other anxiety disorders. Lead author Eli R. Lebowitz, PhD, associate director of the Anxiety and Mood Disorders Program, reports that oxytocin is “implicated in anxiety regulation and in modulating close interpersonal and attachment behavior, underscoring its potential for informing the interpersonal aspects of youth anxiety disorders…leading to the hypothesis that oxytocinergic functioning plays a role in youth anxiety and its disorders and the resulting family accommodation.”^5,6

Changes in the amygdala may also play a role in SAD. Significant disruption in caregiving is associated with childhood separation anxiety symptoms as well as altered functional development of the amygdala, which is a neurobiological correlate of anxious behavior.⁷ One study found that a history of institutional care was associated with reduced differential amygdala responses in children to social-affective cues of trustworthiness.⁷ Individual differences in the degree of amygdala differential responding to these cues predicted the severity of separation anxiety symptoms over the course of a 2-year period.⁷

Vicious Cycle

“It is important to pay attention to a common mechanism that drives separation anxiety, which is the reciprocal nature of parent-child interactions,” Dr Silverman noted.

“We know there are certain children who are temperamentally shy, withdrawn, or are behaviorally inhibited, and we know that anxiety runs in families. So when a child who is shy or anxious shows distress upon separating from the parent, an overanxious parent might seek to spare the child distress and anxiety, and may decide to stay with the child,” she explained.

A cycle develops, or a “protection trap,” in which the child learns to show distress because he or she achieves the goal of having the parent’s continued presence, and the parent learns that not separating from the child reduces the child’s distress.

Although the heavy reliance on parents for help in regulating and avoiding feelings of anxiety, a process called family accommodation, can help alleviate the anxious child’s distress in the short term, it maintains the anxiety in the long run.⁶

Evaluating Potential SAD

Children who present with SAD may show reluctance to fall asleep without being near the parent or caregiver, excessive distress at the prospect of separation from the caregiver, nightmares, or homesickness, Dr Silverman said. The child may also experience frequent physical or somatic symptoms.⁸⁸

Several disorders may mimic SAD and should be ruled out before SAD is diagnosed (Table 2). Depending on the presenting symptoms, family medical history, and course of the symptoms (eg, sudden vs gradual), a medical workup might be appropriate. (Table 3).

“It is good to start with a relatively brief rating scale that can be completed by the child and the parent,” Dr Silverman advises.

Helpful scales include the Screen for Child Anxiety Related Emotional Disorders Revised (SCARED-R, parent and child versions),^9,10 and the Multidimensional Anxiety Scale for Children (MASC).¹¹

It may not be necessary to routinely administer these scales to all children, she added, but if the parent is expressing concerns, or if the clinician observes behavior suggesting separation anxiety (eg, an older child who will not remain alone in the room with the nurse), screening could be useful.

Treatment Approaches

“Cognitive-behavioral therapy (CBT) is the most evidence-based intervention for treating children with SAD,” Dr Silverman emphasizes.

CBT includes psychoeducation, exposure to separation experiences for children with SAD, and cognitive of self-control strategies.^12,13

Psychoeducation enables children to begin understanding how anxiety manifests (eg, physical sensations, avoidance, or particular thoughts). Children learn to identify the situations in which their thoughts arise, what their thoughts are, and how they react to these thoughts. Children who experience somatic reactions can be taught techniques such as relaxation strategies to enable them to start facing their fears instead of avoiding them. Educating children is the first phase of treatment.

The children are also provided with training in cognitive or self-control strategies they may use to face their fears. For example, the STOP (scared, thoughts, other thoughts or other things I can do to handle my fear, and praise myself for handling my fear and exposure) can be a helpful mnemonic for children to remember these newly acquired skills.

Application is the second phase of treatment, in which children (and parents, if they are involved) practice the principles and procedures acquired in the earlier sessions. Applications take place during sessions and out of sessions as homework. Children advance through increasingly difficult anxiety-provoking exposure tasks (eg, parents may be asked to leave the child with a babysitter for increasingly longer intervals).

Relapse prevention is when the therapist works with the child to devise strategies to adopt if “slips” occur.

Numerous studies have supported the use of CBT for SAD. For example, a recent study comparing a 12-week CBT for SAD intervention with a 12-week waiting period found that 76.19% of children allocated to the treatment group definitively no longer fulfilled Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for SAD at follow-up compared with 13.64% in the waiting list group.¹⁴

If a child’s symptoms are attributable to non-SAD causes (eg, fear of bullies or gangs or an academic or language problem), these should be addressed with the school administration or counselor.

“It is important for parents to learn to distinguish between necessary stepping in to protect the child, such as in a bullying situation, vs modifying their behaviors to ‘protect’ the child from unpleasant fears or memories, such as driving 30 miles out of the way to avoid the child’s discomforts,” Dr Silverman cautioned.

She added that working with parents and children together is important so that parents recognize how their own behaviors contribute to the problem and so that parents and children are all on board with the tasks, techniques, and strategies.

Pharmacotherapies can be used adjunctively, although they are not first-line approaches. The Child-Adolescent Anxiety Multimodal Study compared CBT with sertraline, sertraline plus CBT, and placebo in youth with GAD, social phobia, or SAD and found that combined treatment was superior to sertraline alone and CBT alone, both of which outperformed placebo.¹⁵ A recent re-analysis of the original data found that “combined treatment was paramount for achieving remission in children with high anxiety, whereas less anxious children were likely to remit with any active treatment.”¹⁶

A meta-analysis of 115 studies (n=7719 patients, ranging from 5.4 to 16.1 years old) found that compared with placebo, selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors yielded significant improvement in symptoms of anxiety and in response/remission rates. CBT significantly improved primary anxiety symptoms, remission, and response. Moreover, CBT reduced primary anxiety symptoms more than fluoxetine and improved remission more than sertraline. The combination of sertraline and CBT significantly reduced clinician-reported primary anxiety symptoms and response more than either treatment alone. CBT was associated with fewer dropouts than pill placebo or medications.¹⁷

Antidepressants should be used cautiously. A recent literature review suggested that 6 to 9 months of antidepressant treatment may be sufficient, although some clinicians extend treatment to 12 months.¹⁸

Conclusion

“Separation anxiety can be a serious problem with long-term repercussions,” Dr Silverman said. “CBT can enable children to learn how to separate from their parents and engage in appropriate activities. Working with parents to learn how to interrupt the cycle that perpetuates SAD can also be beneficial.”

References

1. Masi G, Mucci M, Millepiedi S. Separation anxiety disorder in children and adolescents: epidemiology, diagnosis and management. CNS Drugs. 2001;15(2):93-104.
2. American Psychiatric Association. Section II Anxiety. In: American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Washington, DC: American Psychiatric Association Publishers; 2013.
3. Carmassi C, Gesi C, Massimetti E, Shear MK, Dell’Osso L. Separation anxiety disorder in the DSM-5 era. J Psychopathol. 2015;21:365-371.
4. Franz L, Angold A, Copeland W, Costello EJ, Towe-Goodman N, Egger H. Preschool anxiety disorders in pediatric primary care: prevalence and comorbidity. J Am Acad Child Adolesc Psychiatry. 2013;52(12):1294-1303.
5. Lebowitz ER, Silverman WK, Martino AM, Zagoory-Sharon O, Feldman R, Leckman JF. Oxytocin response to youth–mother interactions in clinically anxious youth is associated with separation anxiety and dyadic behavior. Depress Anxiety. 2017;34(2):127-136.
6. Lebowitz ER, Leckman JF, Feldman R, Zagoory-Sharon O, McDonald N, Silverman WK. Salivary oxytocin in clinically anxious youth: associations with separation anxiety and family accommodation. Psychoneuroendocrinology. 2016;65:35-43.
7. Green SA, Goff B, Gee DG, et al. Discrimination of amygdala response predicts future separation anxiety in youth with early deprivation. J Child Psychol Psychiatry. 2016;57(10):1135-1144. 
8. Dufton LM, Dunn MJ, Compas BE. Anxiety and somatic complaints in children with recurrent abdominal pain and anxiety disorders. J Pediatr Psychol. 2009;34(2):176-186.
9. Van Meter A, You DS, Halverson T, et al. Diagnostic efficiency of caregiver report on the SCARED for identifying youth anxiety disorders in outpatient settings. J Clin Child Adolesc Psychol. 2016:1-15. 
10. Ivarsson T, Skarphedinsson G, Andersson M, Jarbin H. The validity of the screen for child anxiety related emotional disorders revised (SCARED-R) scale and sub-scales in Swedish youth. Child Psychiatry Hum Dev. 2018;49(2):234-243.
11. Silverman WK, Nelles WB. The anxiety disorders interview schedule for children. J Am Acad Child Adolesc Psychiatry. 1988;27(6):772-778.
12. Silverman WK, Berman SL. Psychosocial interventions for anxiety disorders in children: status and future directions. In: Silverman WK, Treffers PDA, eds. Anxiety Disorders in Children and Adolescents: Research, Assessment, and Intervention. Cambridge, UK: Cambridge University Press; 2001:313-334.
13. Silverman WK, Kurtines WM. Anxiety and Phobic Disorders: A Pragmatic Approach. New York, NY: Plenum Press; 1996.
14. 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(4):206-215.
15. Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med. 2008;359(26):2753-2766.
16. Taylor JH, Lebowitz ER, Jakubovski E, Coughlin CG, Silverman WK, Bloch MH. Monotherapy insufficient in severe anxiety? Predictors and moderators in the child/adolescent anxiety multimodal study. J Clin Child Adolesc Psychol. 2018;47(2):266-281.
17. Wang Z, Whiteside SPH, Sim L, et al. Comparative effectiveness and safety of cognitive behavioral therapy and pharmacotherapy for childhood anxiety disorders: a systematic review and meta-analysis. JAMA Pediatr. 2017;171(11):1049-1056.
18. Hathaway EE, Walkup JT, Strawn JR. Antidepressant treatment duration in pediatric depressive and anxiety disorders: how long is long enough? Curr Probl Pediatr Adolesc Health Care. 2018;48(2):31-39.

Table 1

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Diagnostic Criteria for Separation Anxiety Disorder

1. Inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least 3 of the following: Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures.  Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death. Persistent and excessive worry about experiencing an untoward event (eg, getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure. Persistent reluctance or refusal to go out, be away from home, go to school, go to work, or go elsewhere because of fear of separation. Persistent and excessive fear or reluctance about being alone or without major attachment figures at home or in other settings. Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure. Repeated nightmares involving the theme of separation. Repeated complaints of physical symptoms (eg, headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated.

2. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults.

3.The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.

4. The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder, delusions or hallucinations concerning separation in psychotic disorders, refusal to go outside without a trusted companion in agoraphobia, worries about ill health or other harm befalling significant others in generalized anxiety disorder, or concerns about having an illness in illness anxiety disorder.

American Psychiatric Association. Section II Anxiety. In: The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Washington, DC: American Psychiatric Association; 2013. 

Table 2

Differential Diagnosis of SAD

Inappropriate academic placement Avoidance of school because of bullying, teasing, or fear of violence Truancy Conduct disorder Substance abuse/dependence Depression Grief reaction Brain tumor Communication disorder Post-traumatic stress disorder Panic disorder Selective mutism Learning disabilities or other academic issues Language difficulties

Bernstein BE, et al. Separation anxiety and school refusal differential diagnoses. https://emedicine.medscape.com/article/916737-differential. Updated January 19, 2018. Accessed March 21, 2018.

Table 3

Medical Workup for SAD

Test	Rationale
Thyroid Panel	Rule out thyroid abnormalities
2-hour postprandial glucose test	Rule out type 1 or type 2 diabetes
Titer measurements (especially important in patients with a history that includes fever, rash, sore throat without appropriate antibiotic treatment, and a history of acute change in personality or anxiety/obsessive features)	Rule out: Lyme disease Antistreptococcal antibodies Babesia Rickettsial illness
Blood levels of lead/heavy metals (in the presence of abdominal pain)	Rule out lead or heavy metal poisoning
Complete blood cell count, including measurements of hematocrit and hemoglobin concentrations (if child is presenting with abdominal pain or fatigue)	Rule out anemia
Urine screening	Rule out stimulant, steroid, cannabis use
Gastrointestinal testing (if child is presenting with abdominal pain, nausea, vomiting, diarrhea)	Rule out lactose intolerance, other gastrointestinal disorders

Bernstein et al. Separation anxiety and school refusal workup. https://emedicine.medscape.com/article/916737-workup. Updated January 19, 2018. Accessed March 20, 2018.Radhakrishnan K. Back-to-school difficulties for children with chronic gastrointestinal problems. https://health.usnews.com/health-care/for-better/articles/2017-09-05/back-to-school-difficulties-for-children-with-chronic-gastrointestinal-problems. September 5, 2017. Accessed March 20, 2018.