Separation Anxiety Disorder and School Refusal in Children and Adolescents

摘要

After completing this article, readers should be able to: JC is a 9-year-old boy who lives with his mother and attends the third grade, where he is an A student. During the last 2 weeks, he has refused to go to school and has missed 6 school days. He is awake almost all night worrying about going to school. As the start of the school day approaches, he cries and screams that he cannot go, chews holes in his shirt, pulls his hair, digs at his face, punches the wall, throws himself on the floor, and experiences headaches, stomachaches, and vomiting. If he attends school, he is less anxious until bedtime. As his separation anxiety has increased, he has become gloomy, has stopped reading for fun, and frequently worries about his mother’s tachycardia.JC was seen once by a psychiatrist at age 3 years for problems with separation anxiety. He did well in preschool and kindergarten. He was seen at a community mental health center during the first grade for school refusal, but did well again during the second grade. In addition to having recurrent symptoms of separation anxiety disorder, he is phobic of dogs, avoids speaking and writing in public, and has symptoms of generalized anxiety disorder and obsessive-compulsive disorder. His mother has a history of panic disorder. Pediatricians are familiar with separation anxiety as a normal developmental phenomenon from approximately 10 months of age to the early preschool years. Separation anxiety disorder (SAD), however, is a common childhood anxiety disorder that often involves persistent problems with attending school or other activities away from home because of fear of separation. The fear associated with leaving the safety of parents and home may escalate into tantrums or panic attacks and cause significant interference with academic, social, or emotional development. The efficacy of psychosocial and psychopharmacologic treatments for SAD has been demonstrated in randomized, controlled trials. The essential feature of SAD is excessive anxiety about separation from parents and other attachment figures. The reactions to separation are extreme and beyond that expected for the person’s developmental level. The current diagnostic criteria in the Diagnostic and Statistical Manual for the Mental Disorders (DSM-IV; American Psychiatric Association, 1994) define the disorder with specific requirements about the number, duration, onset, and severity of symptoms and with exclusions of other conditions (Table 1).The definition of SAD is complicated by several issues. Because separation anxiety is a normal developmental phenomenon from late in the first postnatal year to the early preschool years, it can be difficult during those ages to discriminate pathologic from normal forms of separation anxiety. The clinical manifestations of separation anxiety have considerable developmental variation that also raises practical challenges for parents and clinicians. Finally, because there is extensive comorbidity among most childhood anxiety disorders, some have suggested that current diagnostic categories lack discriminant validity and reflect artificial boundaries.SAD is one of the more common childhood anxiety disorders, with prevalence estimates ranging from 3.2% to 4.1%. Because it is more frequent before puberty, the prevalence of the disorder appears to decrease with age. The prevalence of separation anxiety symptoms without significant interference is much higher, with up to 50% of 8-year-olds reporting such symptoms. The disorder in epidemiologic samples is more frequent in females, but there have been no sex differences in some clinical samples.Peak age at onset is in middle childhood, around 7 to 9 years of age. Onset may be as early as preschool age and, by definition, may occur at any time before age 18 years. In one large clinical sample, children who had SAD had the earliest age at onset (mean=7.5 y) and the youngest age at intake (mean=10.3 y) compared with children who had other anxiety diso