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|Separation anxiety disorder|
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|Separation anxiety disorder|
|Classification and external resources|
Separation anxiety disorder (SAD) is a psychological condition in which an individual experiences excessive anxiety regarding separation from home or from people to whom the individual has a strong emotional attachment (e.g. a parent, grandparents, and/or siblings). SAD is characterized by significant and recurrent amounts of worry upon (or in anticipation of) separation from a child or adolescent's home or from those to whom the child or adolescent is attached. Different epidemiological studies indicate a prevalence of 4 to 5% in children and adolescents. Unlike other anxiety disorder between 50%to 75% of children with SAD come from homes with a a low socioeconomic status. In contrast to other anxiety disorders, 50 to 75% of children with SAD come from homes of low socioeconomic status. The severity of symptom's ranges from anticipatory uneasiness to full-blown anxiety about separation. One of the fist symptoms of SAD results in school refusal. School refusal is reported in about 75% of children with SAD, and SAD is reported to occur in up to 80% of children with school refusal. Longitudinal studies have suggested that childhood SAD may be a risk factor for other anxiety disorders. 
Separation anxiety may cause significant impairment in important areas of functioning, (e.g., academic and social). The duration of this problem must last for at least four weeks and must present itself before the child is 18 years of age.
Separation anxiety disorder should not be confused with separation anxiety, which occurs as "a normal stage of development for healthy, secure babies." Separation anxiety occurs as babies begin to understand their own selfhood—or understand that they are a separate person from their primary caregiver. At the same time, the concept of object permanence emerges—which is when children learn that something still exists when it is not seen or heard. As babies begin to understand that they can be separated from their primary caregiver, they do not understand that their caregiver will return, nor do they have a concept of time. This, in turn, causes a normal and healthy anxious reaction. Compared to separation anxiety, separation anxiety disorder is when the symptoms of separation anxiety become problematic for day-to-day living.
Separation anxiety disorder is characterized by some of the following symptoms:
The main concern for children with separation anxiety disorder is that something terrible will happen to their parents or primary caregiver, or that they will become permanently separated from their parents or primary caregiver and this fear is what creates the disorder. Separation anxiety disorder may be a symptom of a co-morbid condition. Children with separation anxiety disorder are much more likely to have ADHD, bipolar disorder, panic disorder, and other disorders later in life.[unreliable medical source?]
Separation anxiety usually occurs between 12 and 18 months. Separation anxiety disorder is usually first reported during the preschool years. The condition can begin at any age up to 18, but onset during late adolescence is not common. Children with SAD become very anxious when separated from figures of attachment (e.g. parents, siblings, or other caregivers) and upon leaving their homes. In anticipation of the separation, they may have somatic complaints and symptoms, such as headaches or stomachaches. While separated from a loved one, children with SAD often fear that something catastrophic may happen to the attachment figure, and they may desire to keep in contact with this person by phone or other means of communication. When these children are away from their homes, they can become extremely homesick and distraught.
Individuals with SAD may worry about losing their parents or getting lost or kidnapped. They often refuse to go to certain places (e.g., school) because of fears of separation, or become extremely fearful when they are left alone without their parents. SAD may appear after a major stress in your child's life. This may come from the loss of a loved one or pet, or from an illness. Moving to a new neighborhood or school may also cause stress to your child. These children and adolescents may also refuse to sleep alone, experience nightmares about separation, or experience various physical complaints (e.g., body-aches, nausea) when separated from their parents.
It is crucial to differentiate separation anxiety disorder from other disorders, especially anxiety disorders, as the two can be confused. To achieve this, children are asked what they fear will happen upon separation. Their answer to this question is a way to determine if they are suffering from separation anxiety disorder. Children who fear something terrible may happen to their parents or primary caregiver, or that they will be permanently separated from their parents or primary caregiver, serves as an indication that the child is suffering from separation anxiety disorder.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (2000) lists criteria that must be fulfilled for a patient to be diagnosed with separation anxiety disorder. These diagnostic criteria include<http://behavenet.com/separation-anxiety-disorder></ref>:
A. Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following:
(1) recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated (2) persistent and excessive worry about losing, or about possible harm befalling, major attachment figures (3) persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped) (4) persistent reluctance or refusal to go to school or elsewhere because of fear of separation (5) persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings (6) persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home (7) repeated nightmares involving the theme of separation (8) repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated
B. The duration of the disturbance is at least 4 weeks.
C. The onset is before age 18 years.
D. The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.
E. The disturbance does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and, in adolescents and adults, is not better accounted for by Panic Disorder with Agoraphobia.
Specify if: Early Onset: if onset occurs before age 6 years
Proposed changes for SAD in the DSM-V (to be published in May 2013) include changing the examples of untoward events happening to the child, the examples in DSM-IV are restricted to untoward events happening to the child, but fail to capture untoward events to attachment figures that may lead to loss. Among those, worries about death and dying are common. Terms are added/deleted to increase the relevance to adults with Separation Anxiety Disorder (e.g., A 4 – “work”, A 5 – removal of “adults” since attachment figures may not be always adults (e.g. for adults, attachment figures can be partners or children)<http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=118#></ref>. The duration will increase from four weeks to typically lasting at least six months to minimize overdiagnosis of transient fears. The text will clarify that this cut off should not be applied too rigidly. However, a caveat permits shorter durations in cases of acute onset or exacerbation of severe symptoms. The Specifier for SAD (Early onset before age 6 years) in the DSM-IV will be deleted in the fifth edition as there is no evidence for such a specifier and because in all anxiety disorders age of onset could be specified as a continuous variable.
Non-pharmacological treatments are methods of treatment that do not involve drugs. Non-pharmacological treatments are to be used before using pharmacological treatments.
Behavioral therapy are types of nonpharmacological treatment which are mainly exposure-based techniques. This covers techniques such as: systematic desensitization, emotive imagery, participant modelling and contingency management. Children are forced to go to school and eventually show decreasing symptoms of SAD.
Contingency management is a form of treatment found to be effective for younger children with SAD. Contingency management revolves around a reward system with verbal or tangible reinforcement. When children under-going contingency management show signs of independence they are praised or given a reward. Children in pre-school who show symptoms of SAD do not have the communicative ability to express their emotions or the self-control ability to cope with their separation anxiety on their own, so parental involvement is crucial in younger cases of SAD.
Cognitive behavioral therapy (CBT) are the same as behavioral therapy with the inclusion of cognitive therapy. According to Kendall and colleagues, there are four components which must be taught to a child under-going CBT
The method behind CBT is that faulty cognition is the reason for the anxiety of SAD. A 1998 study of CBT on children nine and younger found 64% of the treated children did not meet the DSM's criteria for SAD. Only 5% of the wait-listed children in the study showed these results.
Cognitive procedures is a form of treatment found to be ideal for older children with SAD. The theory behind this technique is that the child's dysfunctional thoughts, attitudes, and beliefs are what lead to anxiety and cause anxious behavior. Child who are being treated with cognitive procedures are taught to ask themselves if there is "evidence" to support their anxious thoughts and behaviors. They are taught "coping thoughts" to use during anxiety inducing situations and to praise themselves for handling the situation bravely.
Pharmacological treatment is used in extreme cases of SAD when non-pharmacological treatments fail, typically for school refusal. However, children with school refusal may have conditions other than SAD. Pharmacological management of SAD includes the use of selective serotonin reuptake inhibitors.
As with other anxiety disorders, children with SAD face more obstacles at school than those without anxiety disorders. Adjustment and relating school functioning have been found to be much more difficult for anxious children. Additionally SAD is a common cause of a child’s refusal to attend school. This is a serious problem because as children become further behind in course work, it becomes increasingly hard for them to return to school.
Present in all age groups, adult separation anxiety disorder (affecting roughly 7% of adults) is more common than childhood separation anxiety disorder (affecting approximately 4% of children).
The prevalence of SAD is usually cited as between 3.5% and 5.4%. However, a much higher percentage of children suffer from a smaller amount of separation anxiety, and are not actually diagnosed. Multiple studies have found higher rates of SAD in girls than in boys, and that paternal absence may increase the chances of SAD in girls.
Onset of SAD can either be acute or insidious. Children with acute onset usually make a full recovery, with no apparent long-term effects. Acute onset is usually due to a significant stressor in the child's life such as moving to a new house, moving to a new school, or the divorce of their parents.