Excerpt from Anxiety Disorder: Separation Anxiety and School Refusal

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Background

According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), separation anxiety is a fairly common anxiety disorder that consists of excessive anxiety beyond that expected for the child's developmental level related to separation or impending separation from the attachment figure (eg, primary caretaker, close family member) occurring in children younger than 18 years and lasting for at least 4 weeks.¹

Features include clinically significant symptoms of anxiety (ie, severe distress or impairment of function), unrealistic worries about the safety of loved ones, reluctance to fall asleep without being near the primary attachment figure, excessive distress (eg, tantrums) when separation is imminent, nightmares with separation-related themes, and homesickness (ie, desire to return home or make contact with the caregiver when the child is separated). In addition, physical/somatic symptoms (especially frequent in older children and adolescents), such as dizziness, lightheadedness, nausea, stomachache, cramps, vomiting, muscle aches, or palpitations, may be present and problematic, causing the child and family to seek medical treatment because of impaired ability to attend school or meet social responsibilities.

Pathophysiology

Separation anxiety is developmentally normal in infants and toddlers until approximately age 3-4 years, when mild distress and clinging behavior occur when children are separated from their primary caregivers or attachment figures (eg, being left in a daycare setting). Research results regarding hormonal influences during pregnancy and the neonatal period suggest that maternal endocrine activation during pregnancy (eg, exposure to adrenocorticotropic hormone [ACTH], dexamethasone, or conditions that cause their release) and/or early separation or loss (eg, the neonate not being raised by the original primary caregiver) may result in lower cortisol levels overall and may correlate later in development with clinically significant symptoms of anxiety, learned helplessness, and depression.

Some children may be more vulnerable to separation anxiety based on their temperament (ie, level of anxiety dealing with new situations) or based on environmental stresses such as the death of a close relative or an interactive pattern with an over-protective, needy, or depressed parent. Transient developmental fears (eg, fear of the dark) are generally normal and do not interfere with normal functioning or result in long-term developmental difficulty; however, studies show a subgroup of children who do not meet the criteria for diagnosis of an anxiety disorder but who may have substantial impairment later in life. Studies of children who, in first grade, present with significant symptoms of anxiety (enough to cause clinically significant impairment in social and academic functioning) reflect a correlation with significant impairment in reading and math achievement 5-6 years later.

Frequency

United States

The prevalence ranges from 1.3% in teenagers aged 14-16 years to 4.1-4.7% in children aged 7-11 years. In 1987, Burke et al reported that 5% of school-aged children are identified as school refusers.² In 2005, the Centers for Disease Control prioritized identifying why students do not graduate high school. As many as 40% of students who do not graduate high school have a diagnosable mental health disorder; up to half of those individuals may have anxiety disorders such as posttraumatic stress disorder (PTSD) and school phobia.

International

In 1990, Bowen et al reported a 2.4% overall prevalence rate.³

Mortality/Morbidity

Extremely rare instances of mortality occur in severe separation anxiety. In "mothering to death" cases in the United Kingdom, the primary caregiver of an initially physically healthy child (generally an only child) interacted with the child in such a way that the child was perceived and behaved as physically ill and helpless; as adults, these children functioned as dependent and feeble individuals. In one such case in the United Kingdom, the child became disabled and died.⁴ This example is reflective of unchanging dysfunctional parent-child interaction at home. This example is reflective of unchanging dysfunctional parent-child interaction at home.

• Mortality generally results from associated major depression that may lead to suicide.
• Long-term follow-up studies of children successfully treated for school refusal because of separation anxiety reveal some children with continued impairment of social functioning (ie, social and affective constriction) despite having returned to school; this may reflect the long-term impairment and morbidity and unchanging dysfunctional parent-child interaction at home.

Race

No specific differences in prevalence rates are noted for specific racial or cultural groups; however, somewhat increased incidence has been reported among families of lower socioeconomic status as well as single parent families.

Sex

The prevalence is approximately equal between males and females. In 1984, Granell de Aldaz et al reported that the prevalence of school refusal was equal for boys and girls.⁵

Age

Mean onset of separation anxiety disorder is at age 7.5 years. Mean onset of school refusal is at age 10.3 years.

• Separation anxiety disorder is most frequent among younger children. One study lists prevalence rates for children aged 7-11 years at 4.1%; the same study lists prevalence rates for children aged 12-14 years at 3.9% and a prevalence rate of 1.3% for adolescents aged 14-16 years.
• Separation anxiety disorder manifests slightly differently in different age groups. Children younger than 8 years tend to present with unrealistic worry about harm to their parents or attachment figures and school refusal. Children aged 9-12 years tend to present with excessive distress at times of separation (eg, sleepaway camp, overnight school trips). Adolescents aged 12-16 years more commonly present with school refusal and somatic problems involving autonomic symptoms, such as headaches, dizziness, lightheadedness, sweatiness, or GI or musculoskeletal symptoms (eg, stomachache, nausea, cramps, vomiting, muscle or body aches such as back pain or muscle tension).

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