ANXIETY
DISORDERS OF
CHILDHOOD OR ADOLESCENCE
This subclass includes disorders in which
anxiety is the predominant clinical feature.
In the first two categories, Separation
Anxiety Disorder and Avoidant Disorder of
Childhood or Adolescence, the anxiety is
focused on specific situations. In the third
category, Overanxious Disorder, the anxiety
is generalized to a variety of situations.
Separation
Anxiety Disorder
The essential feature of this disorder is
excessive anxiety, for at least two weeks,
concerning separation from those to whom the
child is attached. When separation occurs,
the child may experience anxiety to the point
of panic. The reaction is beyond that
expected for the child's developmental level.
Onset of the disorder is before age 18. The
diagnosis is not made if the anxiety occurs
exclusively during the course of a Pervasive
Developmental Disorder, Schizophrenia, or any
other psychotic disorder.
Children with Separation Anxiety Disorder
are uncomfortable when they travel
independently away from the house or from
other familiar areas. They may refuse to
visit or sleep at friends' homes, to go on
errands, or to attend camp or school. (It
should be noted that some cases of school
refusal are not due to separation anxiety; in
such cases, usually in adolescence, the child
actually fears the school situation because
of anxiety about social or academic
performance, whether or not he or she is
accompanied by a parent.) Children with
Separation Anxiety Disorder may be unable to
stay in a room by themselves, and may display
"clinging" behavior staying close
to the parent, "shadowing" the
parent around the house. Physical complaints,
such as stomachaches, headaches, nausea, and
vomiting, are common when separation is
anticipated or occurs. Cardiovascular
symptoms such as palpitations, dizziness, and
faintness are rare in younger children, but
may occur in adolescents.
When separated from significant others to
whom they are attached, these children are
often preoccupied with morbid fears that
accidents or illness will befall those to
whom they are attached or themselves. They
often express fear of being lost and never
being reunited with their parents. The exact
nature of the fantasized mishaps varies. In
general, young children have less specific,
more amorphous concerns. As the child becomes
older, the fears may become systematized
around identifiable potential dangers. Many
children, even some older ones, do not report
fears of definite threats, but only pervasive
anxiety about ill-defined dangers or death.
Children also typically exhibit anticipatory
anxiety when separation is threatened or
impending; young children experience distress
only when separation actually occurs.
Children with this disorder often have
tears of animals, monsters, and situations
that are perceived as presenting danger to
the integrity of the family or themselves.
Consequently, they may have exaggerated fears
of muggers, burglars, kidnappers, car
accidents, or plane travel. Concerns about
dying and death are common.
These children often have difficulty going
to sleep, and may insist that someone stay
with them until they fall asleep. They may
make their way to their parents' bed (or that
of another significant person, such as a
sibling); if entry to the parental bedroom is
barred, they may sleep outside the parents
door. Nightmares, whose content expresses the
child's morbid fears, may occur.
Some children do not experience morbid
apprehension about possible harm befalling
them or those close to them, but instead are
extremely homesick and uncomfortable, to the
point of misery, or even panic, when away
from home. These children yearn to return
home, and are preoccupied with reunion
fantasies. When not with a major attachment
figure, children with this disorder may
exhibit recurrent instances of social
withdrawal, apathy, sadness, or difficulty
concentrating on work or play. Occasionally,
a child may become violent toward a person
who is forcing separation. Children with
Separation Anxiety Disorder may refuse to see
relatives or former friends in order to avoid
having to account for their difficulties in,
or absence from, school or from other
activities that they avoided.
Adolescents with this disorder, especially
boys, may deny overconcern about their mother
or their wish to be with her; yet their
behavior reflects anxiety about separation:
they are reluctant or unable to leave the
home or the parent, and feel comfortable only
in situations in which no separation is
demanded.
Although the disorder represents a form of
phobia, it is not included among the Phobic
Disorders because it has unique features and
is characteristically associated with
childhood.
Associated features. Fear of
the dark is common, and some children have
fixed fears that may appear bizarre. For
example, they may report that they see and
feel eyes staring at them in the dark, that
mythical animals are glaring at them, or that
bloody creatures are reaching for them.
Depressed mood frequently is present, and may
become more persistent over time, justifying
an additional diagnosis of Dysthymia or Major
Depression.
Children with this disorder are often
described as demanding, intrusive, and in
need of constant attention. They may complain
that no one loves them or cares about them
and that they wish they were dead, especially
if separation is enforced. Others are
described as unusually conscientious,
compliant, and eager to please.
When no demands for separation are made,
children with Separation Anxiety Disorder
typically have no interpersonal difficulties.
Age at onset. The age at
onset may be as early as preschool age; by
definition, it is before the age of 18. Onset
in adolescence is rare.
Course. Typically there are periods of
exacerbation and remission over a period of
several years. In some cases both the anxiety
about possible separation and the avoidance
of situations involving separation (e.g.,
going away to college) persist for many
years.
Impairment. In its severe
form, the disorder may be very
incapacitating, in that the child is unable
to attend school and function independently
in a variety of areas.
Complications. The child
often undergoes elaborate physical
examinations and medical procedures because
of numerous somatic complaints. When school
refusal occurs, common complications are
academic difficulties and social avoidance.
Predisposing factors. No
specific premorbid personality disturbance is
associated with Separation Anxiety Disorder.
In most cases the disorder develops after
some life stress, typically a loss, the death
of a relative or pet, an illness of the child
or a relative, or a change in the child's
environment, such as a school change or a
move to a new neighborhood.
Children with this disorder tend to come from
families that are close-knit and caring. The
etiologic significance of this familial
pattern is not clear. Neglected children are
underrepresented among those with Separation
Anxiety Disorder.
Prevalence. The disorder is
apparently not uncommon.
Sex ratio. The disorder is
apparently equally common in males and
females.
Familial pattern. The
disorder is apparently more common in
first-degree biologic relatives than in the
general population, and may be more frequent
in children of mothers with Panic Disorder.
Differential diagnosis. In
early childhood some degree of separation
anxiety is a normal phenomenon, and clinical
judgment must be used in distinguishing this
from the clearly excessive reaction to
separation seen in Separation Anxiety
Disorder. In Overanxious Disorder, anxiety is
not focused on separation. In Pervasive
Developmental Disorders or Schizophrenia,
anxiety about separation may occur, but is
viewed as due to these conditions rather than
as a separate disorder. In Major Depression
occurring in children, the diagnosis of
Separation Anxiety Disorder should also be
made when the criteria for both disorders are
met. Panic Disorder with Agoraphobia is
uncommon before age 18, and the fear is of
being incapacitated by a panic attack rather
than of separation from parental figures. In
some cases of Panic Disorder with Agoraphobia
in adolescents or young adults, however, many
of the symptoms of Separation Anxiety
Disorder may be present. In Conduct Disorder,
truancy is common, but the child stays away
from the home, and anxiety about separation
is usually not present.
Diagnostic Criteria for separation
Anxiety Disorder
A. Excessive anxiety
concerning separation from those to whom the
child is attached, as evidenced by at least
three of the following:
- unrealistic and persistent worry
about possible harm befalling major
attachment figures or fear that they
will leave and not return
- unrealistic and persistent worry that
an untoward calamitous event will
separate the child from a major
attachment figure, e.g., the child
will be lost, kidnapped, killed, or
be the victim of an accident
- persistent reluctance or refusal to
go to school in order to stay with
major attachment figures or at home
- persistent reluctance or refusal to
go to sleep without being near a
major attachment figure or to go to
sleep away from home
- persistent avoidance of being alone,
including "clinging" to and
"shad-owing" major
attachment figures
- repeated nightmares involving the
theme of separation
- complaints of physical symptoms,
e.g., headaches, stomachaches,
nausea, or vomiting, on many school
days or on other occasions when
anticipating separation from major
attachment figures
- recurrent signs or complaints of
excessive distress in anticipation of
separation from home or major
attachment figures, e.g., temper
tantrums or crying, pleading with
parents not to leave
- recurrent signs of complaints of
excessive distress when separated
from home or major attachment
figures, e.g., wants to return home,
needs to call parents when they are
absent or when child is away from
home
B. Duration of
disturbance of at least two weeks.
C. Onset before the age of
18.
D. Occurrence not
exclusively during the course of a Pervasive
Developmental Disorder, Schizophrenia, or any
other psychotic disorder.
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