Childhood Separation Anxiety Disorder Research Articles

A Genetically Informed Study of the Association Between Childhood Separation Anxiety, Sensitivity to CO2, Panic Disorder, and the Effect of Childhood Parental Loss

Childhood separation anxiety disorder can predate panic disorder, which usually begins in early adulthood. Both disorders are associated with heightened sensitivity to inhaled CO(2) and can be influenced by childhood parental loss. To find the sources of covariation between childhood separation anxiety disorder, hypersensitivity to CO(2), and panic disorder in adulthood and to measure the effect of childhood parental loss on such covariation. Multivariate twin study. Seven hundred twelve young adults from the Norwegian Institute of Public Health Twin Panel, a general population cohort. Personal direct assessment of lifetime panic disorder through structured psychiatric interviews, history of childhood parental loss, and separation anxiety disorder symptoms. Subjective anxiety response to a 35% CO(2)/65% O(2) inhaled mixture compared with compressed air (placebo). Our best-fitting solution yielded a common pathway model, implying that covariation between separation anxiety in childhood, hypersensitivity to CO(2), and panic disorder in adulthood can be explained by a single latent intervening variable influencing all phenotypes. The latent variable governing the 3 phenotypes' covariation was in turn largely (89%) influenced by genetic factors and childhood parental loss (treated as an identified element of risk acting at a family-wide level), which accounted for the remaining 11% of covariance. Residual variance was explained by 1 specific genetic variance component for separation anxiety disorder and variable-specific unique environmental variance components. Shared genetic determinants appear to be the major underlying cause of the developmental continuity of childhood separation anxiety disorder into adult panic disorder and the association of both disorders with heightened sensitivity to CO(2). Inasmuch as childhood parental loss is a truly environmental risk factor, it can account for a significant additional proportion of the covariation of these 3 developmentally related phenotypes.

The Implementation of Modified Parent-Child Interaction Therapy for Youth with Separation Anxiety Disorder

Separation Anxiety Disorder (SAD) is the most prevalent anxiety disorder experienced by children, and yet empirical treatment studies of SAD in young children are virtually nonexistent. This paper will describe the development and implementation of an innovative treatment for SAD in young children. First, we will highlight the rationale for developing interventions specifically for SAD in young children. Second, we will describe an existing empirically supported treatment, Parent-Child Interaction Therapy (PCIT; Brinkmeyer, M. Y., & Eyberg, S.M., (2003)), that may have particular applicability to very young children with SAD and their parents. We present how results from 10 pilot participants were utilized to modify PCIT to better address the needs of children with SAD and their families. The benefits and challenges of implementing this modified version of PCIT are reviewed, along with potential directions for future research in this area.

Separation Anxiety Disorder in Childhood as a Risk Factor for Future Mental Illness

To ascertain the extent to which childhood separation anxiety disorder (SAD) confers risk for the development of psychopathology during young adulthood (ages 19-30). A subset of the participants of the Oregon Adolescent Depression Project (n = 816) was used. Subjects provided retrospective reports of lifetime mental illness (including SAD) and concurrent reports of current mental illness at age 16 and were then followed prospectively until age 30. Diagnostic assessments were conducted twice during adolescence and again at ages 24 and 30. Based on diagnosis during childhood/adolescence, the subjects were partitioned into four orthogonal groups: SAD (n = 42), other anxiety disorders (n = 88), a heterogeneous psychiatric disorders control group (n = 389), and a not mentally ill control group (n = 297). Adjusting for demographic variables that were significantly associated with group status and for comorbid disorders prior to age 19, the results were analyzed with hierarchical multiple logistic regression. SAD was a strong (78.6%) risk factor for the development of mental disorders during young adulthood. The major vulnerabilities were for panic disorder and depression. Because SAD creates a major vulnerability for mental disorders during young adulthood, clinicians should be sensitive to the presence of SAD, and children and adolescents with SAD should be treated. Future research should evaluate whether successful treatment of SAD and/or the provision of a preventive intervention during childhood/adolescence reduce the risk for future psychopathology.

Separation anxiety disorder and school refusal in childhood: potential risk factors for developing distinct psychiatric disorders?

Separation anxiety disorder and school refusal in childhood: potential risk factors for developing distinct psychiatric disorders?

The Unique Impact of Parent Training for Separation Anxiety Disorder in Children

This investigation examined the preliminary efficacy of an integrated cognitive-behavioral parent-training protocol for six families of separation-anxious children (7 to 10 years of age) using a multiple baseline design across participants. Although families were assessed on child, parent, and clinician ratings at pre- and posttreatment as well as 6-month follow-up, only parents received education and training. Although the parent-training protocol was largely effective and treatment gains were maintained at 6-month follow-up, only those child participants whose parents experienced clinically significant improvement on parental process measures (i.e., enhanced efficacy or satisfaction, reduced stress) achieved high end-state functioning. Implications regarding the importance of individualized family-based interventions for treating anxious youth are discussed.

Possible Link Between Childhood Separation Anxiety and Adulthood Personality Disorder in Patients With Anxiety Disorders in Japan

The aim of this study was to examine whether childhood separation anxiety symptoms associate with adulthood anxiety disorders or personality disorders. Separation Anxiety Symptom Inventory (SASI), Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II), and Global Assessment of Functioning (GAF) were administered to 134 outpatients with anxiety disorders and SASI was administered to 176 healthy volunteers (controls) recruited in Japan from April 1999 through November 2003. SASI scores were not correlated with age or sex in controls. In contrast, SASI scores were higher in patients with anxiety disorders than in controls, especially in women. SASI showed good test-retest reliability (Pearson correlation coefficient = 0.8). One hundred thirteen patients (84.3%) had no comorbid anxiety disorder while 21 (15.7%) had any, and those with comorbid anxiety disorder tended to show higher SASI scores (p = .053). In total, 60 (44.8%) of 134 patients had at least 1 personality disorder, and the most frequent disorders were from cluster C (36.6%). The subgroup with comorbid personality disorders showed earlier onset (p < .01), higher SASI scores (p < .01), and poorer recovery of global functioning (p < .05) than the noncomorbid subgroup. Stepwise multiple regression analysis revealed that SASI scores were higher in female (p < .05) and younger (p < .01) patients and most strongly correlated with number of comorbid personality disorders in adulthood (p < .01). These results suggest that there is a continuum of anxiety disorders from childhood to adulthood, the severity of separation anxiety appears to increase the risk of severe anxious-fearful personality disorders in adulthood, and those with severe separation anxiety, particularly females, may progress to suffer from comorbid adult anxiety disorders.

Adult Separation Anxiety Often Overlooked Diagnosis

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessAdult Separation Anxiety Often Overlooked DiagnosisJoan Arehart-TreichelJoan Arehart-TreichelSearch for more papers by this authorPublished Online:7 Jul 2006https://doi.org/10.1176/pn.41.13.0030If the American public were asked to give an example of adult separation anxiety disorder, they might cite the classic Hollywood film“ Casablanca,” where Ilsa (Ingrid Bergman) clings to Rick (Humphrey Bogart) shortly before they part forever. Or they might point to the Hollywood thriller “Psycho,” where lead character Norman Bates (Anthony Perkins) sleeps next to his mother long after she has died.Adult separation anxiety disorder is more than the stuff of Hollywood, though. It afflicts some 7 percent of Americans at some point in their lives, according to a new study.“The results did not really surprise me,” katherine Shear, M.D., a professor of psychiatry at Columbia University and the lead investigator, told Psychiatric News. “Our group in Pittsburgh, as well as colleagues in Australia and in Italy, have observed adult separation anxiety disorder in clinical populations for a number of years now. It is clear that this is an identifiable syndrome.”The investigation conducted by Shear and her colleagues appears to be the first to explore the prevalence of adult separation anxiety disorder in the American population. Data for the inquiry were collected as part of the National Comorbidity Survey Replication, which has already provided a treasure trove of information about the prevalence and treatment of psychiatric disorders (Psychiatric News, July 1 and July 15, 2005).Still other notable insights into adult separation anxiety disorder have emerged from the study by Shear and her team. For example, the prevalence of the disorder in the United States is even greater than that of childhood separation anxiety disorder, which is 4 percent. While some Americans with the adult version first experienced it during childhood, the vast majority encountered it once they reached adulthood. Adult separation anxiety disorder often occurs along with other psychiatric illnesses, especially other anxiety conditions or mood disorders.Further, adult separation anxiety disorder is often associated with personal and social impairment—many Americans with it are poorly educated, unemployed, and unmarried—even when other psychiatric illnesses are not present. And while 75 percent of Americans with the condition are receiving treatment, most are receiving help for comorbid conditions rather than for separation anxiety per se.These results have implications for clinical psychiatrists, Shear believes.“ They need to be aware of the occurrence, prevalence, and comorbidities of this syndrome, which could be confused with agoraphobia and which could complicate another Axis I disorder, since it is co-occurring with so many. Following the principle of measurement-based care, it will be very important to follow these symptoms in patients who are treated for adult separation anxiety and/or co-occurring conditions.”Even with the insights obtained from this study, a lot more needs to be learned about adult separation anxiety disorder, Shear and her group pointed out in their study report, which appeared in the June American Journal of Psychiatry.For instance, when is the dependence of family members on each other culturally determined and acceptable, and when is it pathological? When is angst about separation from a loved one during war, natural catastrophes, or other dire circumstances to be expected, and when is it not? And what are normal and abnormal responses to the loss of a loved one? Shear, in fact, is exploring these issues (Psychiatric News, August 20, 2004; July 15, 2005).The study by Shear and her team was financed by the National Institute of Mental Health, John D. and Catherine T. MacArthur Foundation, Pfizer Foundation, U.S. Public Health Service, Pan American Health Organization, Eli Lilly and Co., and GlaxoSmithkline.“Prevalence and Correlates of Estimated DSM-IV Child and Adult Separation Anxiety Disorder in the National Comorbidity Survey Replication” is posted at<http://ajp.psychiatryonline.org/cgi/content/full/163/6/1074?>.▪ ISSUES NewArchived

Prevalence and Correlates of Estimated DSM-IV Child and Adult Separation Anxiety Disorder in the National Comorbidity Survey Replication

Despite its inclusion in DSM-IV, little is known about the prevalence or correlates of adult separation anxiety disorder or its relationship to the childhood disorder. Results of the first epidemiological study of adult separation anxiety disorder, to the authors' knowledge, and its relationship to childhood separation anxiety disorder are presented. Data were from the National Comorbidity Survey Replication (NCS-R), a nationally representative survey of U.S. households. A fully structured, lay-administered diagnostic interview assessed a wide range of DSM-IV disorders, including separation anxiety disorder. No independent clinical validation was obtained of the assessment. Lifetime prevalence estimates of childhood and adult separation anxiety disorders were 4.1% and 6.6%, respectively. Approximately one-third of the respondents who were classified as childhood cases (36.1%) had an illness that persisted into adulthood, although the majority classified as adult cases (77.5%) had first onset in adulthood. The assessment of separation anxiety disorder in the NCS-R was comorbid with other NCS-R or DSM-IV disorders and associated with severe role impairment in roughly half of the comorbid cases and one-fourth of the pure cases. The majority of people with estimated adult separation anxiety disorder are untreated, even though many obtain treatment for comorbid conditions. Criteria for adult separation anxiety disorder should be refined in future editions of DSM because the disorder is likely to be much more common in adults than previously recognized. Research is needed to develop and evaluate treatments that take into consideration its high comorbidity with other DSM-IV disorders.

Prevalence and Correlates of Estimated DSM-IV Child and Adult Separation Anxiety Disorder in the National Comorbidity Survey Replication

Objective: Despite its inclusion in DSM-IV, little is known about the prevalence or correlates of adult separation anxiety disorder or its relationship to the childhood disorder. Results of the first epidemiological study of adult separation anxiety disorder, to the authors’ knowledge, and its relationship to childhood separation anxiety disorder are presented. Method: Data were from the National Comorbidity Survey Replication (NCS-R), a nationally representative survey of U.S. households. A fully structured, lay-administered diagnostic interview assessed a wide range of DSM-IV disorders, including separation anxiety disorder. No independent clinical validation was obtained of the assessment. Results: Lifetime prevalence estimates of childhood and adult separation anxiety disorders were 4.1% and 6.6%, respectively. Approximately one-third of the respondents who were classified as childhood cases (36.1%) had an illness that persisted into adulthood, although the majority classified as adult cases (77.5%) had first onset in adulthood. The assessment of separation anxiety disorder in the NCS-R was comorbid with other NCS-R or DSM-IV disorders and associated with severe role impairment in roughly half of the comorbid cases and one-fourth of the pure cases. The majority of people with estimated adult separation anxiety disorder are untreated, even though many obtain treatment for comorbid conditions. Conclusions: Criteria for adult separation anxiety disorder should be refined in future editions of DSM because the disorder is likely to be much more common in adults than previously recognized. Research is needed to develop and evaluate treatments that take into consideration its high comorbidity with other DSM-IV disorders.

Parental Intrusiveness and Children’s Separation Anxiety in a Clinical Sample

In this article, a theoretical model of the role of parental intrusiveness in the development of childhood separation anxiety disorder is presented and tested. Parents who act intrusively tend to take over tasks that children are (or could be) performing independently, thereby limiting mastery experiences and inducing dependence on caregivers. Families of children diagnosed with an anxiety disorder, aged 6-13 years, participated (N = 40). Child anxiety was assessed with a diagnostic interview and rating scales. A novel measure of intrusiveness based on behavioral observations and self-reports was developed, following seven principles for enhancing the psychometric properties of parenting measures. There was initial evidence of strong psychometric properties for the intrusiveness measure, which was associated with children's separation anxiety symptoms, but as predicted, not with other types of anxiety symptoms. Parental intrusiveness appears to be specifically linked with separation anxiety among children with anxiety disorders.

Parent-child interaction therapy for treatment of separation anxiety disorder in young children: A pilot study

Research suggests that Parent-Child Interaction therapy (PCIT) works to improve the child's behavior by changing the child-parent interaction. PCIT has been effective in treating disruptive behavior in young children. This article describes a pilot study to apply PCIT to the treatment of separation anxiety disorder (SAD). A multiple-baseline design was used with 3 families with a child between the ages of 4 and 8 who had a principal diagnosis of SAD. Following treatment with PCIT, clinically significant change in separation anxiety was observed on all measures. Disruptive behaviors also decreased following treatment. Treatment gains were maintained at a 3-month follow-up interval. These findings suggest that PCIT may be particularly useful for treatment of young children with SAD, the most prevalent yet underresearched anxiety disorder of childhood. The results of this study support research delineating the important contribution of family factors to anxiety in childhood. Several mechanisms are proposed that may account for the dramatic decrease in separation-anxious behaviors seen in children during PCIT, including increased levels of child control, increased social reinforcement of brave behaviors, improved parent-child attachment, and decreased levels of parent anxiety. Results of this study provide promising initial evidence that PCIT may be efficacious for treating young children with SAD. A randomized clinical trial is warranted to further elucidate the efficacy of PCIT for treatment of SAD in young children.

Clinical correlates and significance of separation anxiety in patients with bipolar disorder

To evaluate frequency and severity of separation anxiety (SA) symptoms, as well as frequency of DSM-IV diagnosis of childhood separation anxiety disorder (CSAD) and adult separation anxiety disorder (ASAD), in a group of patients with bipolar disorder (BD) when compared with patients with panic disorder (PD) or major depression (MDD) and to a control group of healthy individuals (HC). Outpatients with, respectively, bipolar I disorder (BD), PD, MDD and a group of individuals with no psychiatric diagnoses (HC) were assessed for diagnosis by the SCID-I and for SA by the Structured Clinical Interview for Separation Anxiety Symptoms (SCI-SAS), the Separation Anxiety Symptoms Inventory (SASI) and the Adult Separation Anxiety Checklist (ASA-CL). Thirty-one patients with BD without comorbid PD (BD-PD), 22 with BD with comorbid PD (BD + PD), 24 with PD, 20 with MDD and 15 HC were included in the analyses. As to childhood SA, the BD-PD group had higher scores than PD group and HC. The BD + PD group had higher scores than the PD group, MDD group and HC. As to adulthood SA, the BD-PD group had higher scores than HC on both SCI-SAS and Adult Separation Anxiety Questionnaire (ASA-27). The BD + PD had higher scores on both scales than BD-PD, PD group, MDD group and HC. The PD group and MDD group had higher scores than HC on the ASA-27. Adult SA symptoms were significantly associated with an earlier age at onset of BD. This is the first study, to our knowledge, exploring the frequency and severity of SA symptoms during childhood and adulthood in a sample of bipolar patients in comparison to subjects with other anxiety and mood disorders. Our data appear to be preliminary grounds for investigating further the possibility that SA may deserve greater recognition in adults with BD.

Prevalence of Probable Mental Disorders Among Pediatric Asthma Patients in an Inner-City Clinic

Objective. To determine the screen-positive prevalence of anxiety disorders and depression among pediatric asthma patients in an inner-city asthma clinic and to investigate the association between probable diagnoses of anxiety disorders and depression and medical service use among inner-city pediatric asthma patients. Method. In this pilot study, a consecutive sample of pediatric asthma patients aged 5–11 in the waiting room of an inner-city asthma clinic was screened for mental disorders using the DISC Predictive Scales (DPS), which produces probable DSM-IV diagnoses. In addition, data on health service use for asthma were collected. Statistical analyses were performed to examine the relationship between probable anxiety disorders and depression and health service use for asthma among pediatric asthma patients. Results. Approximately one in four (25.7%) pediatric asthma patients in an inner-city asthma clinic met criteria for a probable diagnosis of current anxiety disorders or depression (past 4-week prevalence). Specifically, childhood separation anxiety disorder was common among 8.1%, panic among 14.9%, generalized anxiety disorder among 4.1%, agoraphobia among 5.4%, and 2.7% had depression. Having more than one anxiety disorder or depression diagnosis was associated with higher levels of inpatient and outpatient medical services, compared with patients who were negative on screening for anxiety or depressive disorders, although differences failed to reach statistical significance. Conclusions. These findings are the first to provide preliminary evidence suggesting that mental health problems are common among pediatric asthma patients in an inner-city clinic. The results also suggest that mental health problems in pediatric asthma patients may be associated with elevated levels of medical service use for asthma. Replication of this pilot study is needed with a larger sample, more precise diagnostic methodology, and a comparison group with chronic medical illness.

Is Childhood Separation Anxiety Disorder a Predictor of Adult Panic Disorder and Agoraphobia? A Seven-Year Longitudinal Study

To examine whether separation anxiety disorder (SAD) in childhood is a risk factor for panic disorder and agoraphobia in adulthood. Patients (n = 85) who had completed treatment for SAD, generalized anxiety disorder, and/or social phobia 7.42 years earlier (on average) were reassessed using structured diagnostic interviews. Subjects with a childhood diagnosis of SAD did not display a greater risk for developing panic disorder and agoraphobia in young adulthood than those with other childhood anxiety diagnoses. Subjects with a childhood diagnosis of SAD did not more frequently meet full diagnostic criteria for panic disorder and agoraphobia, generalized anxiety disorder, social phobia, or major depressive disorder in adulthood than subjects with childhood diagnoses of generalized anxiety disorder or social phobia, but were more likely to meet criteria for other anxiety disorders (i.e., specific phobia, obsessive compulsive disorder, posttraumatic stress disorder, and acute stress disorder). These results argue against the hypothesis that childhood SAD is a specific risk factor for adult panic disorder and agoraphobia.

Relationship Between Separation Anxiety Disorder, Parental Panic Disorder, and Atopic Disorders in Children: A Controlled High-Risk Study

To test the hypotheses that rates of atopic disorders are elevated in offspring of parents with panic disorder (PD) and in children with separation anxiety disorder (SAD). Rates of atopic disorders were assessed in 343 offspring (aged 6-17 years) of parents with PD, nonpanic psychiatric disorders, and no psychiatric disorder. Lifetime history of atopic disorders was determined by parental responses to a clinician-administered questionnaire assessing medical treatment for asthma and allergies. Logistic regression analyses assessed the association between atopic disorders and parental PD, and between atopic disorders and probable or definite childhood SAD. Analyses controlled for age, sex, socioeconomic status, and treatment for other medical illnesses. Increased rates of atopic disorders were found in offspring of parents with PD (odds ratio [OR] = 2.56, 95% confidence interval [CI] = 1.27-5.16, p = .009) and in children with SAD (OR = 2.71, 95% Cl = 1.22-6.03, p = .015). Associations remained significant when both parental PD and SAD were included in the model, suggesting that each contributed independently to increased rates of atopy. The interaction of parental PD and child SAD was not significant. Atopic disorders in children are associated with parental PD and with childhood SAD. Results do not appear to support that having both childhood SAD and a parent with PD confers increased risk for atopic disorders above and beyond either condition alone.

Obsessive–compulsive disorder and separation anxiety co-morbidity in early onset panic disorder

This study was undertaken to examine the relationship between anxiety co-morbidity and age of onset of panic disorder. Age of onset of panic disorder and co-morbid anxiety disorders were assessed among 201 panic disorder probands with childhood separation anxiety disorder, obsessive-compulsive disorder, obsessive-compulsive symptoms, social phobia and specific phobia as part of a clinician-administered lifetime diagnostic interview. A generalized linear model was used to test the association between each anxiety co-morbidity and age of panic disorder onset while simultaneously controlling for the potential confounding effects of sociodemographic characteristics and other psychiatric co-morbidity. Earlier onset of panic disorder was found in patients with co-morbid obsessive-compulsive disorder, obsessive-compulsive symptoms and separation anxiety disorder, but not simple phobia or social phobia. Patients with both childhood separation anxiety disorder and obsessive-compulsive disorder had an even earlier panic onset than those with either childhood separation anxiety disorder or obsessive-compulsive disorder. The association between anxiety co-morbidity and earlier onset of panic disorder is specific to obsessive-compulsive disorder and childhood separation anxiety disorder.

Parent–child concordance for separation anxiety: a clinical study

There is tentative evidence supporting a familial basis for separation anxiety. The present study aimed to examine parent–child concordance for that subtype of anxiety. Fifty-four children diagnosed with anxiety disorders and their parents (54 mothers and 29 fathers) were recruited from two juvenile anxiety clinics. Sixty-three percent of children diagnosed with juvenile separation anxiety disorder had at least one parent who suffered from the putative adult variant of the disorder (odds ratio=11.1) ( P<0.001). Affected parents reported high levels of separation anxiety in their own childhoods. Juvenile separation anxiety disorder in children was not associated with any other parental diagnosis. The small sample size and other potential biases caution against definitive conclusions being drawn, but the present data add to existing evidence that separation anxiety may aggregate in families.

Cognitive--Behavioral Therapy with a Six-Year-Old Boy with Separation Anxiety Disorder: A Case Study

Cognitive-behavioral therapy (CBT) has become a respected and empirically established model of psychotherapy. A review of the experimental literature, by a task force established by the American Psychological Association, demonstrated the effectiveness of CBT for adults. In their review, CBT was efficacious for depression, generalized anxiety disorder, social phobia, obsessive compulsive disorder, substance abuse and dependence, agoraphobia, and panic disorder (DeRubeis & Crits-Christoph, 1998). Treating children with emotional and behavioral disorders using CBT has recently been receiving more research and clinical attention (Eisen, Kearney, & Schaefer, 1995; Jayson, Wood, Kroll, Fraser, & Harrington, 1998; Kendall, 1991; March & Mulle, 1998; Reincke, Ryan, & DuBois, 1998). The fundamental principles of CBT that apply to adult disorders can be applied to children, of course, with developmental modifications. Children, as well as adults, with psychological problems make systematic errors in thinking (cognitive distortions) and have skill deficits that maintain the problem (Kendall, 1991). The cognitive model hypothesizes that a person's thinking influences his or her mood and thus, modifications to thinking will result in changes in mood and behavior (Beck, Rush, Shaw, & Emery, 1979). This article is an exploratory study examining the use of cognitive--behavioral therapy in the treatment of separation anxiety disorder (SAD). The main clinical feature of this disorder is excessive worry about the separation from home or from the person to whom the affected person is attached (American Psychiatric Association [APA], 1994). The anxiety must be beyond what is expected for the developmental level and have been present for at least four weeks. Onset of the disorder must occur before 18 years of age. A child with SAD frequently reports fears that involve being kidnapped, becoming lost, or having his or her caretaker become hurt, killed, or kidnapped. When a child with SAD expects to be separated from his or her caretaker or when separation has just occurred, the child displays significant subjective distress. The child may cry, shake, express terror, and have autonomic symptoms of anxiety such as palpitations and hyperventilation (Black, 1995). The prevalence of SAD is estimated to be about 4 percent in children and young adolescents (APA, 1994). CONCEPTUALIZATION Separation anxiety disorder in children has similar clinical features as adults with panic disorder with agoraphobia, such as phobic avoidance, catastrophic interpretations, and panic symptoms. For example, a child with SAD tries to avoid separation from his or her caretaker (phobic avoidance), believes that if separated something terrible will happen and he or she will not be able to handle it (catastrophic interpretations), and experiences autonomic arousal such as palpitations, perspiration, hyperventilation, shaking, and fear (panic symptoms). A child with SAD makes catastrophic interpretations about being separated from his parents. This activates the child's autonomic nervous system, which creates anxiety symptoms, which then serve to reinforce the catastrophic interpretations. The cycle then becomes self-perpetuating. The treatment of panic disorder with agoraphobia in adults typically includes explanation of the nature of anxiety and panic, anxiety-management strategies (breathing, retraining, and relaxation), and cognitive restructuring (Barlow, Craske, Cerny, & Klosko, 1989; Otto & Deckersbach, 1998). Two new features to the treatment of panic by Craske, Meadows, and Barlow (1994) included prescriptive treatment for agoraphobia and the integration of a spouse or partner in exposure-based treatment. Barlow et al. (1989) found that about 90 percent of panic-disordered patients were panic free following their panic-control treatment. Previous treatment of children with SAD focused on medication and psychodynamic, family, or behavioral interventions (Drobes & Strauss, 1993; March, 1995). …

Depressive Symptoms in Children and Adolescents with Dysthymic Disorder

This report examines clinical features of ‘pure’ dysthymic disorder (DD, without superimposed major depressive disorder, MDD) in a sample of children and adolescents. Profiles of symptomatology and comorbidity as a function of age and gender are described. The sample consisted of 48 subjects (22 males, 26 females, age range 7–18 years, mean age 12.1 years) screened from consecutively referred children and adolescents. All subjects were comprehensively diagnosed with structured diagnostic interviews (Schedule for Affective Disorders and Schizophrenia for School Age, Diagnostic Interview for Children and Adolescents-Revised), according to DSM-IV criteria. Depressed mood, irritability, loss of energy and fatigue, guilt and low self-esteem were present in more than 70% of the subjects. Differences in symptomatic profile between males and females were not significant. Children showed less symptoms than adolescents, but the symptomatic profile was comparable (only anhedonia was significantly more frequent in adolescents). Anxiety disorders were more commonly comorbid with DD, especially separation anxiety disorder in children (33%) and generalised anxiety disorder in adolescents (67%). Externalising disorders were less frequently represented in our sample (14%). An early diagnosis of ‘pure’ DD before the first episode of MDD is crucial for a timely intervention.

Separation anxiety disorder in children and adolescents: epidemiology, diagnosis and management.

This paper provides an overview of the phenomenology, longitudinal outcome data, assessment and management of separation anxiety disorder (SAD) in children and adolescents. SAD is qualitatively different from early worries, and is characterised by an abnormal reactivity to real or imagined separation from attachment figures, which significantly interferes with daily activities and developmental tasks. Different epidemiological studies indicate a prevalence of 4 to 5% in children and adolescents. In contrast to other anxiety disorders, 50 to 75% of children with SAD come from homes of low socioeconomic status. The severity of symptomatology ranges from anticipatory uneasiness to full-blown anxiety about separation, but children are usually brought to the clinician when SAD results in school refusal or somatic symptoms. 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, but whether this link is specific to, for example, panic disorder and agoraphobia, or whether SAD represents a general factor of vulnerability for a broad range of anxiety disorders is still debated. Most relevant data are reported on nonpharmacological treatments (psychoeducational, behavioural, cognitive-behavioural, family and psychodynamic), and these are the first choice approach in SAD. Controlled studies show efficacy of cognitive-behavioural therapy in children with anxiety disorders and specifically in SAD-school phobia, supporting this approach as the best proven treatment. Pharmacotherapy should be used in addition to behavioural or psychotherapeutic intervention when the child's symptoms have failed to respond to those treatments, and he/she is significantly impaired by the symptoms. Selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SSRI) have a good adverse effect profile and may be considered as first choice drugs in SAD. When different SSRIs fail to improve symptomatology, a trial with a tricyclic antidepressant (TCA) is indicated, with careful monitoring of cardiac functioning. Because of the adverse effect profile and the potential for abuse and dependence, benzodiazepines should be used only when a rapid reduction of symptomatology is needed, until the SSRI or the TCA have begun to be effective (few weeks). Buspirone should be considered in children who have not responded to other treatments. Further research is needed to confirm efficacy of newer antidepressants (venlafaxine, mirtazapine, nefazodone) in childhood anxiety disorders.