Separation Anxiety Disorder

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Separation Anxiety Disorder: An Overview
According to Kossowsky, Pfaltz, and Schneider, separation anxiety disorder (SAD) is characterized by excessive and persistent fear or anxiety over removal from familiar surroundings or close proximity to attachment figures 768). Separation anxiety disorder in childhood and adulthood is considered developmentally inappropriate if it is beyond the individual’s development level need for proximity to the attachment figures (Milrod, Markowitz and Gerber 35). Separation Anxiety Disorder is frequently diagnosed in children and has a low lifetime prevalence with rates between 4.1% to 5.1% (Kossowsky, Pfaltz and Schneider 768). While separation anxiety is considered a normative part of the developmental process due to the inherent dependency nature of children, SAD has negative implications on the child’s emotional and social well-being as it can result in avoidance of specific activities, places and experiences essential for healthy development (Ehrenreich, Santucci and Weiner 389). SAD also affects the family as a child suffering from the disorder may cause significant interference of everyday life and social well-being of the child. This paper will give a brief overview of the symptoms, etiology, diagnosis, treatment and the clinical implications of the disorder.
SIGNS AND SYMPTOMS
While fear and anxiety are considered a common occurrence in everyday situations, individuals with SAD present excessive or out of proportion anxiety over perceived imminent threat or situation.

Anxiety and fear are also considered normative in childhood and adolescent development which may persist into adulthood. A common symptom of SAD among children is the avoidance of anxiety-inducing situations such as leaving home or separation from a prominent attachment figure. Such behavior stems from the fear that something catastrophic may occur when they are away from a particular place or their attachment figures leading to a refusal to participate in developmentally appropriate activities such as school. The illness may also manifest in somatic symptoms such as headaches, stomachaches, and bouts of nausea usually reported in the context of an anxiety-inducing situation as an avoidant strategy or as physical distress resulting from the anxiety (Ehrenreich, Santucci and Weiner 391). Children with SAD often display difficulty in sleeping, like refusing to sleep without or near the attachment figure or experiencing recurrent nightmares with themes separation.
ETIOLOGY
According to Milrod, Markowitz, and Gerber, SAD has evolutionary causes rooted in epigenetic animal models (35). For instance, some animals would show drastic autonomic responses to separation from their mothers and had a significant reduction in participation in social play activities. Psychological studies have pointed to the existence of a complex interaction of environmental, biological, genetic, and harmful socio-cultural factors behind the development and maintenance of SAD (Ehrenreich, Santucci and Weiner 390). Biological factors refer to an increased risk to develop SAD for children with genetic vulnerabilities to experience anxiety and temperamental behaviors. Past research also indicates an inherent link between the development of the SAD and past diagnosis of other psychiatric disorders such as depression, anxiety, or panic disorders (Dabkowska, Araszkiewicz and Dabkowska 314). Research also indicates a higher prevalence of the disorder in girls than in boys. Behavioral studies highlight the earlier onset of SAD in children with parents with anxiety disorders than their parents. This phenomenon is attributed to learned behavior which parents with anxiety can model fear and anxiety in their offspring and reinforce avoidance patterns of anxiety-provoking situations (Dabkowska, Araszkiewicz and Dabkowska 314). Additionally, lifetime maternal anxiety disorders are correlated to SAD in their children further supporting the genetic theory behind the development of SAD.
Evidence from some studies suggests that shared environmental effects such as parenting behavior are substantively more likely to influence the development of SAD than genetic factors (Ehrenreich, Santucci and Weiner 390). For instance, according to Dabkowska, Araszkiewicz and Dabkowska, children who had experienced a low parental warmth and parenting behaviors which limit autonomy and mastery had a higher chance of developing an anxiety disorder and other childhood developmental disorders (315). Developmental psychology and attachment theories have consistently pointed to the existence of an association between overprotective, and over-critical parenting styles and maintenance of SAD among children. Findings from various studies report an increased risk in the development of SAD with the exposure to stressful events. Maintenance of the condition can also occur following a change in routine, insufficient rest, change in family structure, illnesses or following a traumatic event in a child’s life (Dabkowska, Araszkiewicz and Dabkowska 315).
DIAGNOSIS AND CLINICAL PRESENTATIONS
Anxiety and fear are considered normative in childhood development. Therefore, SAD represents a more serious expression of such symptoms. According to Dabkowska, Araszkiewicz, and Dabkowska, SAD is mostly defined by the presence of persistent symptoms over a period specified in the DSM-IV-TR criteria for such symptoms to be considered pathological (316). The diagnostic criteria vary in children and adults. The DSM-IV-TR assessment criteria for children requires that a child displays at least three of the characteristic symptoms of excessive and developmentally inappropriate anxiety over the removal from the proximity of his or her home or an attachment figure for at least a four-week period (Dabkowska, Araszkiewicz and Dabkowska 316). These symptoms include: persistent excessive distress during or in anticipation of separation from home or attachment figure, recurrent and excessive worry over losing, or harm befalling their attachment figures, repeated and undue worry that a catastrophic event will lead to separation from attachment figure, recurrent refusal ot go to school or elsewhere steming from fear of separation, peristsent and excessive anxiety over being alone without attachment figure, persistent reluctance over going to sleep without close proximity to an attachment figure or away from home, recurrent nighmares centered around separation, persistent complaints of physical distress such as headaches, stomachaches and nausea during a separation event or in its anticipation.
On the other hand, adult SAD is linked to severe role impairment in the workplace and social relationships. Some adults with SAD have a history of childhood SAD which persists into adulthood while others have adulthood onset of the condition (Dabkowska, Araszkiewicz and Dabkowska 326). Symptomatology of adult SAD resembles that of childhood SAD that worsen in the presence of perceived threats. In adulthood, ephemeral fear or anxiety is also common during periods of stress. SAD in adults is commonly diagnosed if the symptoms persist over a period of at least six months (Craske and Stein 199). Adults SAD is frequently associated with other psychiatric conditions. Recent studies into the etiology of adults onset SAD shows that expression of the platelet 18-kDa translocator protein (TSPO) was indicative of adult SAD and other mood comorbidities (Dabkowska, Araszkiewicz and Dabkowska 326).
TREATMENT
Ehrenreich, Santucci, and Weiner observe that the most effective evidence-based therapeutic model for managing anxiety disorders including SAD in children and adolescents involves cognitive behavioral therapy (CBT) (396). CBT consists of the restructuring of cognitive behavior such as relaxation techniques and gradual exposure to anxiety-inducing events that help develop coping mechanisms and reduce anxiety. Empirical studies also highlight the effectiveness of selective serotonin-reuptake inhibitors (SSRI) in the improvement of outcomes in children with SAD (Dabkowska, Araszkiewicz and Dabkowska 327). Pharmacological options for managing pediatric SAD involves benzodiazepines, tricyclics, and buspirone (Dabkowska, Araszkiewicz and Dabkowska 327). Family involvement in CBT as parents play an integral role in the maintenance of SAD symptoms in children.
CLINICAL IMPLICATIONS OF THE DISORDER
According to Milrod, separation anxiety disorder is linked to a number psychiatric comorbidities (601). It is often a precursor to other anxiety disorder such as panic disorder and agoraphobia and for individuals suffering from the disorder and increases the risk for the development of posttraumatic stress disorder (PTSD) resulting from anxiety-provoking stressors. Given that SAD typically has an early onset, research into suitable diagnostic tools for children is necessary to prevent later psychopathology.
CONCLUSION
Anxiety disorders are frequently diagnosed among children and adolescents. Anxiety and fear are normative in childhood development due to the dependent nature of the child. Separation anxiety disorder is a severe form of separation fear from attachment figures where the anxiety is beyond the developmental stage of the child and is no longer adaptive. Diagnostic criteria for SAD requires that children demonstrate symptoms such as persistent and excessive fear of separation from an attachment figure or of catastrophic events occurring the attachment figure in anticipation or during separation consistently over a period of four weeks for it to be clinically significant. Additionally, the illness may be expressed in somatic symptoms such as headaches, nausea, and stomachaches.

Works Cited
BIBLIOGRAPHY l 1033 Craske, Michelle G, and Murray B Stein. “Anxiety.” Focus, vol. 15, no. 2, 2017, pp. 199-210.
Dabkowska, Malgorzata, et al. Separation Anxiety in Children and Adolescents, Different Views of Anxiety Disorders. InTech, 2011.
Ehrenreich, Jill T., Lauren C. Santucci and Courtney L. Weiner. “Separation Anxiety Disorder in Youth: Phenomenology, Assessment, and Treatment.” Psicol Conductual, vol. 16, no. 3. 2008, pp. 389-412.
Kossowsky, Joe, et al. “The Separation Anxiety Hypothesis of Panic Disorder Revisited: A Meta-Analysis.” American Journal of Psychiatry, vol. 170, 2013, pp. 768-781.
Milrod, Barbara. “An Epidemiological Contribution to Clinical Understanding of Anxiety.” American Journal of Psychiatry, vol. 172, 2015, pp. 601-602.
Milrod, Barbara, et al. “Childhood Separation Anxiety and the Pathogenesis and Treatment of Adult Anxiety.” American Journal of Psychiatry, vol. 171, 2014, pp. 34-43.