eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Anxiety Disorder, Separation Anxiety and School Refusal

Author: Bettina E Bernstein, DO, Assistant Professor, Department of Psychiatry, Philadelphia College of Osteopathic Medicine; Private Practice at the Wynnewood House; Consultant, Child Guidance Resource Centers, Early Elementary Education Program, Clinical Affiliate, Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia
Contributor Information and Disclosures

Updated: Dec 3, 2008

Introduction

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 of school refusal and separation anxiety disorder ranges from 1.3% in individuals aged 14-16 years to 4.1-4.7% in children aged 7-11 years with an average prevalence rate of 2-4%. As many as one third of children with separation anxiety disorder have comorbid depressive disorder, and as many as 27% have another disruptive behavior disorder, such as attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder, or conduct disorder.

In 1987, Burke et al reported that 5% of school-aged children refuse to attend school.2 In 2005, the Centers for Disease Control and Prevention (CDC) prioritized the identification of the cause behind students not graduating high school. As many as 40% of students who do not graduate high school have a diagnosable mental health disorder; as many as one half of those individuals may have anxiety disorders such as posttraumatic stress disorder (PTSD) and school phobia.

In 2003, Egger et al reported that among children with anxious school refusal and truancy, as many as 88% had a psychiatric disorder.3 Children with a history of pure truancy had high rates of oppositional defiant disorder (odds ratio, 2.2), depression (odds ratio, 2.6), and conduct disorder (odds ratio, 7.4). Anxious school refusal and truancy are distinct, but not mutually exclusive, disorders; thus, accurate diagnosis of comorbid conditions is important.

In 2001, McShane reported that one half of 192 adolescents with school refusal had a positive family history of psychiatric illness; those admitted for inpatient treatment were more likely to have a diagnosis of comorbid mood disorder and a maternal history of psychiatric illness.4

Separation anxiety disorder may wax and wane over a period of years. Approximately 30-40% of affected individuals have continued psychiatric symptoms into adulthood; as many as 65% in some studies have another comorbid anxiety disorder.5,6

International

In 1990, Bowen et al reported a 2.4% overall prevalence rate.7

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.8 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 "more close-knit" families of lower socioeconomic status, as well as single-parent families.

Sex

The prevalence of separation anxiety disorder is slightly more frequent in females than males; the prevalence of school refusal is approximately equal between males and females.9,7,10

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).

Clinical

History

In assessing patients with separation anxiety, school refusal, or both, history must be obtained from multiple informants, including the patient, parents or caregivers, and other pertinent persons such as teachers and coaches. Screen for features of depression (eg, anhedonia, insomnia, feelings of worthlessness) and ask the child directly about symptoms. The onset and development of symptoms as well as their context helps to establish the diagnosis of anxiety disorder. Noting whether anxiety is stimulus-specific, spontaneous, or anticipatory; if the symptoms result in avoidant behavior (ie, degree of constriction of daily life) that is clinically significant and disabling; and whether social and familial reinforcers of symptoms are present is helpful.

Pertinent educational, developmental, and family or social history should be obtained, including any family history of anxiety disorders and history of separations and losses, school attendance, academic functioning, presence of environmental stressors, and degree of involvement with peer group and social competence.

  • Family history is extremely helpful in elucidating precipitating factors and should be obtained in a therapeutic manner so that the family feels the interviewer understands the emotional stress and is responsive to it.
  • Separation anxiety disorder generally manifests with clinically significant symptoms of anxiety such as unrealistic and recurrent worries about harm of loved ones, especially when separated or faced with threatened separation from the primary attachment figure, along with severe distress and impairment in functioning. Severe distress and impairment in functioning may be indicated by the following signs:
    • Reluctance to fall asleep without being near the primary attachment figure
    • Excessive distress (eg, tantrums) when separation is imminent
    • Nightmares about separation-related themes
    • Homesickness (ie, a desire to return home or make contact with the primary caregiver when separated)
    • Frequent physical or somatic symptoms such as abdominal pain and palpitations
  • The family frequently reinforces separation anxiety symptoms. For example, when the family experiences a major life stress or illness and the child expresses mild refusal to leave the primary caregiver (who may be anxious, distressed, or depressed), the child is not firmly encouraged to appropriately separate and instead is rewarded either overtly or covertly not to separate (ie, when the child who refuses to leave is given extra attention or when the child who refuses to attend school is excused by the parent). In these instances, the parent does not clearly give the child the task of developing strategies to adapt to the separation.
  • Separation anxiety is often the precursor to school refusal, which occurs in approximately three fourths of children who present with separation anxiety disorder.
  • Boys and girls do not significantly differ in symptom presentation.
  • In general, younger children may be referred more often because older children usually present with somatic symptoms, which may not be as clearly correlated with situations of imminent or actual separation from attachment figures.

Physical

Generally, somatic symptoms, such as palpitations or abdominal pain, have no clear physical origin. However, a careful physical examination with appropriate blood work is recommended to rule out physical causes, including occult serologic streptococcal infection; hyperthyroidism; hypothyroidism; mitral valve prolapse; asthma; or GI infection, inflammation, bleeding, or ulceration.

  • When approaching the child and family, reassure both the child and family that somatic symptoms are indicators of a problem that is serious and requires attention. Psychological interventions should proceed simultaneously with medical evaluations.
  • To help prevent secondary gain, encourage the child and family to live as normal a life as possible (despite the symptoms) to prevent worsening impairment of functioning. This includes returning to school immediately if school refusal is an issue.
  • To help prevent secondary complications, do not be overzealous in the workup for a physical etiology of the somatic problems; however, do be prudent.

Causes

Studies show that children of adults with anxiety disorders have higher rates of anxiety disorders. Experts have postulated that early and traumatic separation from the attachment figure (as well as a family history of anxiety disorders or depression in first-degree relatives) may increase the likelihood of the child and, later on, the adolescent or adult developing separation anxiety disorder, school phobia, and depressive-spectrum disorders. Examples of early and traumatic separation include a prolonged stay away from the primary caregiver during the neonatal period, later sudden hospitalization, and early loss of attachments because of death or divorce. Hormonal changes (eg, exposure prenatally to increased levels of ACTH), which may result from stress, may also increase the likelihood of these disorders.

More on Anxiety Disorder, Separation Anxiety and School Refusal

Overview: Anxiety Disorder, Separation Anxiety and School Refusal
Differential Diagnoses & Workup: Anxiety Disorder, Separation Anxiety and School Refusal
Treatment & Medication: Anxiety Disorder, Separation Anxiety and School Refusal
Follow-up: Anxiety Disorder, Separation Anxiety and School Refusal
References
[ CLOSE WINDOW ]

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Further Reading

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Keywords

school phobia, separation anxiety disorder, excessive anxiety, severe distress, tantrums, nightmares, extreme homesickness, psychosomatic symptoms, clinging behavior, daycare, depression, suicide, truancy, skipping school, school refusal, learned helplessness, transient developmental fears, posttraumatic stress disorder, anhedonia, insomnia, feelings of worthlessness, occult serologic streptococcal infection, hyperthyroidism, hypothyroidism, mitral valve prolapse, asthma, depressive-spectrum disorders, diabetes mellitus, Lyme disease, Rocky Mountain spotted fever

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Contributor Information and Disclosures

Author

Bettina E Bernstein, DO, Assistant Professor, Department of Psychiatry, Philadelphia College of Osteopathic Medicine; Private Practice at the Wynnewood House; Consultant, Child Guidance Resource Centers, Early Elementary Education Program, Clinical Affiliate, Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia
Bettina E Bernstein, DO is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry and American Psychiatric Association
Disclosure: Nothing to disclose.

Medical Editor

Angelo P Giardino, MD, PhD, Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc
Angelo P Giardino, MD, PhD is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, Helfer Society, and International Society for Prevention of Child Abuse and Neglect
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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