Separation Anxiety Disorder in SchoolAge Children What Health Care Providers Should Know
Separation Anxiety Disorder in SchoolAge Children What Health Care Providers Should Know
Separation Anxiety Disorder in SchoolAge Children What Health Care Providers Should Know
Separation Anxiety
Disorder in School-Age
Children: What Health
Care Providers Should
Know
Jerrica Vaughan, MSN, RN, CPNP-PC,
Jennifer A. Coddington, DNP, MSN, RN, CPNP,
Azza H. Ahmed, DNSc, RN, IBCLC, CPNP, &
MaryLou Ertel, MS, BSN, RN, CPNP-PC
1. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is
attached, as evidenced by at least three of the following:
(a) Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment
figures.
(b) Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as
illness, injury, disasters, or death.
(c) Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having
an accident, becoming ill) that causes separation from a major attachment figure.
(d) Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of
separation.
(e) Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in
other settings.
(f) Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment
figure.
(g) Repeated nightmares involving the theme of separation.
(h) Repeated complaints of physical symptoms (e.g., 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 exces-
sive 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 befall-
ing significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, (DSM-5Ò). American Psychiatric Pub.
Retrieved from http://dsm.psychiatryonline.org.ezproxy.lib.purdue.edu/doi/full/10.1176/appi.books.9780890425596.dsm05#BABBCCGJ
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright q2013). American Psy-
chiatric Association. All Rights Reserved.
assess other domains of anxiety. These screening all children with SAD (Brewer & Sarvet, 2011). When
tools, outlined in Table 1, can be administered to par- CBT alone is not sufficient to treat children with SAD,
ents and/or children. One downfall of these screening a combination therapy should be explored. The child/
tools is that they can be difficult to administer in adolescent anxiety multimodal study is a randomized
younger children, who have not developed the verbal clinical trial that looked at the efficacy of a CBT and ser-
and cognitive skills needed to accurately report symp- traline (Rapp et al., 2013). This study concluded that
toms (Allen et al., 2010). Another barrier to providers combination therapy of both CBT and sertraline (an
administering these tools is that each takes an average SSRI) resulted in significant improvement of anxiety
of 5 to 10 minutes to complete. However, these symptoms (Rapp et al., 2013). Therefore, children with
screening tools, along with a thorough history and SAD ages 6 years and older are best treated with a com-
evaluation, can aid in the diagnosis of SAD. bination of an SSRI and CBT when both are available
(Mohatt, Bennett, & Walkup, 2014). There are not any
MANAGEMENT medications approved for children younger than 6 years
SADs in pediatrics can be treated with psychological, of age, so those younger than 6 years should be treated
behavioral, and pharmacologic interventions. There with CBT alone.
have been multiple studies that look at the efficacy of
these treatments, and current recommendations include Psychotherapeutic
the use of cognitive behavioral therapy (CBT) and selec- There are multiple techniques that can be used to
tive serotonin reuptake inhibitors (SSRIs; Rapp, Dodds, help children with SAD develop coping strategies,
Walkup, & Rynn, 2013). CBT is the first-line treatment for and these techniques are generally used as