due is 24 hours

Mash, E. J. (2016). Abnormal Child Psychology, 6th Edition. [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/9781305809758/

11 Anxiety and Obsessive—Compulsive Disorders

It is hard to be brave, when you're only a very small animal.

—Piglet (Pooh's Little Instruction Book, 1995)

CHAPTER PREVIEW

DESCRIPTION OF ANXIETY DISORDERS

· Experiencing Anxiety

· Anxiety versus Fear and Panic

· Normal Fears, Anxieties, Worries, and Rituals

· Anxiety Disorders According to DSM-5

SEPARATION ANXIETY DISORDER

· Prevalence and Comorbidity

· Onset, Course, and Outcome

· School Reluctance and Refusal

SPECIFIC PHOBIA

· Prevalence and Comorbidity

· Onset, Course, and Outcome

SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA)

· Prevalence, Comorbidity, and Course

SELECTIVE MUTISM

· Prevalence, Comorbidity, and Course

PANIC DISORDER AND AGORAPHOBIA

· Prevalence and Comorbidity

· Onset, Course, and Outcome

GENERALIZED ANXIETY DISORDER

· Prevalence and Comorbidity

· Onset, Course, and Outcome

OBSESSIVE–COMPULSIVE AND RELATED DISORDERS

· Obsessive–Compulsive Disorder

· Prevalence and Comorbidity

· Onset, Course, and Outcome

ASSOCIATED CHARACTERISTICS

· Cognitive Disturbances

· Physical Symptoms

· Social and Emotional Deficits

· Anxiety and Depression

GENDER, ETHNICITY, AND CULTURE

THEORIES AND CAUSES

· Early Theories

· Temperament

· Family and Genetic Risk

· Neurobiological Factors

· Family Factors

TREATMENT AND PREVENTION

· Overview

· Behavior Therapy

· Cognitive–Behavioral Therapy (CBT)

· Family Interventions

· Medications

· Prevention

· Separation Anxiety: Brad is terrified of being separated from his mother. He follows her around the house constantly, always needing to know where she is.

· Social Anxiety: Li-Ming is very preoccupied with what others think of her. She doesn't interact with anyone at school, and feels completely isolated.

· Panic Disorder: Claudia describes her sudden attack of overwhelming anxiety. “My heart started pumping so fast I thought it would explode. I thought I was going to die.”

· Generalized Anxiety: Jared “worries about everything”—how he is doing in school, events in the news, and family finances.

· Obsessive–Compulsive Disorder: Georgina can't stop thinking about not being able to sleep. Every night before bedtime she goes through the same routine of counting and grouping all the clothes and shoes in her bedroom closet and opening and closing the closet door.

ALL CHILDREN EXPERIENCE FEAR, worry, or anxiety as a normal part of growing up, but each child in our examples suffers from an anxiety or related disorder that is excessive and debilitating. An anxiety disorder is one of the most common mental health problems in young people, with lifetime prevalence estimates between 8% and 30% (Kessler et al., 2012a; Merikangas et al., 2010). Estimates vary widely with the child's age, type of anxiety disorder, and whether impaired functioning is part of the diagnosis. Conservatively, at least one child in every elementary school classroom is likely to have an anxiety disorder (Cartwright-Hatton, McNicol, & Doubleday, 2006). Despite their early onset, high frequency, persistence, and associated problems, anxiety disorders in children often go unnoticed and untreated (Gregory et al., 2007). Fewer than 20% of youngsters with anxiety disorders receive services for their problem, as compared with about 45 % to 60 % of those with conduct or attention disorders (Merikangas et al., 2011). This may be due to the frequent occurrence of fears and anxiety during normal development, the invisible nature of many symptoms (e.g., a knot in the stomach), and the fact that anxiety is not nearly as damaging to other people or property as are conduct problems (Higa-McMillan, Francis, & Chorpita, 2014).

   For a long time, anxiety in children was thought to be a mild and transitory disturbance that would fade over time with normal life experiences. However, we now know that many children who experience anxiety display impairments in their school, social, and family/home functioning and will continue to display anxiety and other problems into adolescence and adulthood (Bittner et al., 2007; Langley et al., 2014). Having an anxiety disorder in childhood or adolescence is also one of the strongest predictors of most other later mental disorders (Kessler et al., 2012c). Although isolated symptoms of fear and anxiety are usually short-lived, anxiety disorders have a more chronic and stable course (Carballo et al., 2010). In fact, nearly half of those affected have an illness duration of 8 years or longer (Keller et al., 1992), and parents' reports of their child's anxiety symptoms predict anxiety disorders 24 years later (Reef et al., 2010). The societal costs for clinically anxious youths are also substantial, with estimated costs (e.g., health care, child care, missed work or school days) about 20 times higher for families with an anxious child versus those from the general population (Bodden, Dirksen, & Bögels, 2008). Thus, anxiety disorders in children are common, distressing, long-lasting, and costly (Rapee, Schneiring, & Hudson, 2009).

   We begin our discussion with anxiety disorders, the primary focus of this chapter. We also discuss obsessive–compulsive disorder (OCD), a closely related disorder that was considered to be one of the anxiety disorders in previous versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM). OCD is now included in a separate chapter of DSM-5, with related disorders such as hoarding, hair-pulling, skin-picking, and body dysmorphic disorder (i.e., perceived defects or flaws in physical appearance). As we shall discuss, there is a close relationship between the anxiety disorders and some of these disorders (especially OCD), with respect to their behavioral and cognitive symptoms and other features.

DESCRIPTION OF ANXIETY DISORDERS

Anxiety is a mood state characterized by strong negative emotion and bodily symptoms of tension in which the child apprehensively anticipates future danger or misfortune (Barlow, 2002). This definition captures two key features of anxiety—strong negative emotion and an element of fear. Children who experience excessive and debilitating anxieties are said to have anxiety disorders. These disorders occur in many forms. Some children, like Brad, feel anxious whenever they are separated from their mother or are away from home. Others feel anxious only in certain situations, such as when they have to travel by airplane or, like Li-Ming, when they have to give a talk in class. Some youngsters, like Claudia, have unpredictable bouts of such sudden and intense anxiety that they become terrified and immobilized. Others, like Jared, worry about almost everything and feel anxious most of the time for no apparent reason. Some children, like Georgina, experience repeated, intrusive, and unwanted thoughts that produce anxiety, and they spend hours in ritualized behavior in an effort to alleviate that anxiety.

   Many youngsters with anxiety disorders suffer from more than one type, either simultaneously or at separate times during their development (Costello, Egger, & Angold, 2005b). In view of the substantial overlap among these disorders, we begin this chapter by discussing the general features and mechanisms of anxiety that apply across all types. The common occurrence of fears and anxieties in childhood and adolescence requires that we also consider the role of these emotions in normal development. We then examine each anxiety disorder and what makes it unique.

Experiencing Anxiety

· When Isabella saw a dog running loose in front of her house, she became pale, sweaty, cold, and trembly. Her thoughts raced so fast that she couldn't think. She froze. Her heart pounded, she felt tense, and she found it difficult to breathe.

Isabella is experiencing anxiety in response to an event she sees as potentially threatening or dangerous. As humans, we are programmed to detect and react to signs of anxiety in ourselves and in others. In fact, anxiety is both expected and normal at certain ages and in certain situations. One-year-old infants become distressed when separated from their mothers, and almost all young children have short-lived specific fears—of the dark, for example. The child's world can be a strange and menacing place, full of unknown dangers—some real, others imagined. Although no one likes to feel anxious, not feeling anxious when the situation calls for it is far worse.

   Anxiety often hits us when we do something important, and in moderate doses it helps us think and act more effectively. You will probably be better prepared for your next exam if you're just a little bit nervous about taking it. Similarly, some anxiety may help a child prepare harder for an upcoming oral report or athletic event. In this sense, anxiety is an adaptive emotion that readies children both physically and psychologically for coping with people, objects, or events that could be dangerous to their safety or well-being.

   Although some anxiety is good, too much is not. Excessive, uncontrollable anxiety can be debilitating. A child may fail a test because she spends too much time thinking about how awful it would be to fail, making it nearly impossible to think about anything else (e.g., how to solve a math problem). In children with anxiety disorders, this normally useful emotion works against them.

   When children experience fears beyond a certain age, in situations that pose no real threat or danger, and to an extent that seriously interferes with daily activities, anxiety is a serious problem. Even if the child knows there is little to be afraid of, he or she is still terrified and does everything possible to escape or avoid the situation. This pattern of self-defeating behavior, known as the neurotic paradox (Mowrer, 1950), can become self-perpetuating—much like Sisyphus repeatedly pushing the rock up the hill, only to have it roll back down each time.

   First and foremost, anxiety involves an immediate reaction to perceived danger or threat—a reaction known as the fight/flight response. All of its effects are aimed at escaping potential harm, either by confronting the source of danger (fight) or by evading it (flight). If you look up to see a grand piano about to fall in your direction and experience no anxiety whatsoever, you will pay serious consequences. To avoid such a fate, your fight/flight response would kick into overdrive and you would jump out of harm's way.

   Think of a recent situation that made you anxious. What was it about the situation that made you anxious? What physical symptoms did you notice? What were you thinking? What did you do? Describing what it's like to be anxious is not easy, because anxiety is a complex reaction with many symptoms, as shown in Table 11.1. How many of these symptoms did you experience? What do these many symptoms have in common?

Youngsters with anxiety experience strong negative emotion and physical tension, and anticipate future danger.

TABLE 11.1 | The Many Symptoms of Anxiety

Physical
Increased heart rate	Dizziness	Blushing
Fatigue	Blurred vision	Vomiting
Increased respiration	Dry mouth	Numbness
Nausea	Muscle tension	Sweating
Stomach upset	Heart palpitation
Cognitive
Thoughts of being scared or hurt	Thoughts of incompetence or inadequacy	Thoughts of bodily injury
Thoughts or images of monsters or wild animals	Difficulty concentrating	Images of harm to loved ones
Self-deprecatory or self-critical thoughts	Blanking out or forgetfulness	Thoughts of going crazy
	Thoughts of appearing foolish	Thoughts of contamination
Behavioral
Avoidance	Trembling lip	Avoidance of eye contact
Crying or screaming	Swallowing	Physical proximity
Nail biting	Immobility	Clenched jaw
Trembling voice	Twitching	Fidgeting
Stuttering	Thumb sucking

   The symptoms of anxiety are expressed through three interrelated response systems: the physical system, the cognitive system, and the behavioral system. It is essential to know how the three sets of symptoms work, since more than one may be evident in different children with the same anxiety disorder. Also, as we will discuss, different response systems are more dominant in certain anxiety disorders. Let's take a closer look at how each response system works.

Physical System

When a person perceives or anticipates danger, the brain sends messages to the sympathetic nervous system, which produces the fight/flight response. The activation of this system produces many important chemical and physical effects that mobilize the body for action:

· ▸ Chemical effects. Adrenaline and noradrenaline are released from the adrenal glands.

· ▸ Cardiovascular effects. Heart rate and strength of the heart beat increase, readying the body for action by speeding up blood flow and improving delivery of oxygen to the tissues.

· ▸ Respiratory effects. Speed and depth of breathing increase, which brings oxygen to the tissues and removes waste. This may produce feelings of breath-lessness, choking or smothering, or chest pains.

· ▸ Sweat gland effects. Sweating increases, which cools the body and makes the skin slippery.

· ▸ Other physical effects. The pupils widen to let in more light, which may lead to blurred vision or spots in front of the eyes. Salivation decreases, resulting in a dry mouth. Decreased activity in the digestive system may lead to nausea and a heavy feeling in the stomach. Muscles tense in readiness for fight or flight, leading to subjective feelings of tension, aches and pains, and trembling.

   These physical symptoms are familiar signs of anxiety. Overall, the fight/flight response produces general activation of the entire metabolism. As a result, the individual may feel hot and flushed and, because this activation takes a lot of energy, he or she feels tired and drained afterward.

Cognitive System

Since the main purpose of the fight/flight system is to signal possible danger, its activation produces an immediate search for a potential threat. For children with anxiety disorders, it is difficult to focus on everyday tasks because their attention is consumed by a constant search for threat or danger. When these children can't find proof of danger, they may turn their search inward: “If nothing is out there to make me feel anxious, then something must be wrong with me.” Or they may distort the situation: “Even though I can't find it, I know there's something to be afraid of.” Or they may do both. Children with anxiety disorders will invent explanations for their anxiety: “I must be a real jerk.” “Everyone will think I'm a dummy if I say something.” “Even though I can't see them, there are germs all over the place.” Activation of the cognitive system often leads to subjective feelings of apprehension, nervousness, difficulty concentrating, and panic.

Behavioral System

The overwhelming urges that accompany the fight/flight response are aggression and a desire to escape

the threatening situation, but social constraints may prevent fulfilling either impulse. For example, just before a final exam you may feel like attacking your professor or not showing up at all, but fortunately for your professor and your need to pass the course, you are likely to inhibit these urges! However, they may show up as foot tapping, fidgeting, or irritability (consider the number of teeth marks in pencils) or as escape or avoidance by getting a doctor's note, requesting a deferral, or even faking illness. Unfortunately, avoidance perpetuates anxiety, despite the temporary feeling of relief. Avoidance behaviors are negatively reinforced; that is, they are strengthened when they are followed by a rapid reduction in anxiety. As a result, each time a child is confronted with an anxiety-producing situation, the faster she or he gets out of it, the faster the anxiety drops off—so the more the child avoids such situations. As children with anxiety disorders engage in more and more avoidance, carrying out everyday activities becomes exceedingly difficult.

CHANTELLE: The Terror of Being Home Alone

When Chantelle, age 14, realized she was at home alone, she was terrified. Her thoughts raced so fast it was impossible to think clearly. She forgot all the right things to do. Her heart pounded and she tensed up. She felt like she couldn't breathe, and she began to sob. She wanted to run but felt completely immobilized. (Based on authors' case material.)

   Chantelle's reactions show how the three response systems of anxiety interact and feed off one another. Physically, Chantelle's heart pounded, she tensed, and she had difficulty breathing. Cognitively, she could not think clearly. Behaviorally, she was completely immobilized.

Anxiety versus Fear and Panic

It is important to distinguish anxiety from two closely related emotions—fear and panic. Fear is an immediate alarm reaction to current danger or life-threatening emergencies. Although fear and anxiety have much in common, the fear reaction differs both psychologically and biologically from the emotion of anxiety. Fear is a present-oriented emotional reaction to current danger marked by a strong escape tendency and an all-out surge in the sympathetic nervous system. The overriding message is alarm: “If I don't do something right now, I might not make it at all.” In contrast, anxiety is a future-oriented emotion characterized by feelings of apprehension and lack of control over upcoming events that might be threatening. Fear and anxiety both warn of danger or distress. However, only anxiety is frequently felt when no danger is actually present (Barlow, 2002).

   Panic is a group of physical symptoms of the fight/flight response that unexpectedly occur in the absence of any obvious threat or danger. With no explanation for physical symptoms such as a pounding heart, the child may invent one: “I'm dying.” The sensations themselves can feel threatening and may trigger further fear, apprehension, anxiety, and panic (Barlow, 2002).

Normal Fears, Anxieties, Worries, and Rituals

Since fear and anxiety in moderate doses are adaptive, it is not surprising that emotions and rituals that increase feelings of control are common during childhood and adolescence. It is only when the emotions and rituals become excessive, occur in a developmentally inappropriate context, or lead to impairment in functioning such as an inability to go to school, make friends, complete academic tasks, or meet other developmental goals that they are of concern.

Normal Fears

Since young people and their environments constantly change, fears that are normal at one age can be debilitating a few years later. For example, fear of strangers may serve a protective function for infants and young children, but when it persists beyond a certain age it can seriously interfere with the development of peer relations (Brooker et al., 2013). Whether or not a specific fear is normal also depends on its effect on the child and how long it lasts. If a fear has little impact on the child's daily life or lasts only a few weeks, it is likely a part of normal development.

   The number and types of common childhood fears change over time, with a general age-related decline in number (Gullone, 1999). Even so, specific fears are common in older children, and many teens report that their fears cause them considerable distress and significantly interfere with daily activities (Ollendick & King, 1994). Girls tend to have more fears than boys at almost every age; they also rate themselves as more fearful and report fears that are more intense and disabling than do boys. Although fears show a general decline with age, some, such as school-related fears,

remain stable; others, such as social fears, may increase (Muris, 2007). Common fears and anxieties of infants, children, and adolescents are shown in Table 11.2. Also shown are possible relevant symptoms and corresponding DSM-5 anxiety disorders that may develop in relation to these symptoms.

TABLE 11.2 | Common Fears and Anxieties of Infancy, Childhood, and Adolescence; Possible Symptoms; and Corresponding DSM-5 Diagnoses

Developmental Period	Age	Common Fears and Anxieties	Possible Symptoms	Corresponding DSM-5 Anxiety Disorder
Early Infancy	Within first weeks	Loss of physical support, loss of physical contact with caregiver	—	—
	0–6 months	Intense sensory stimuli (loud noises)	—	—
Late Infancy	6–8 months	Shyness/anxiety with stranger, sudden, unexpected, or looming objects	—	Separation anxiety disorder
Toddlerhood	12–18 months	Separation from parent, injury, toileting, strangers	Sleep disturbances, nocturnal panic attacks, oppositional defiant behavior	Separation anxiety disorder, panic attacks
	2–3 years	Fears of thunder and lightning, fire, water, darkness, nightmares	Crying, clinging, withdrawal, freezing, avoidance of salient stimuli (e.g., turning the light on), night terrors, enuresis	Specific phobias (natural environment), panic attacks
		Fears of animals	—	Specific phobias (animal)
Early Childhood	4–5 years	Separation from parents, fear of death or dead people	Excessive need for reassurance	Separation anxiety disorder, generalized anxiety disorder, panic attacks
Primary/Elementary School Age	5–7 years	Fear of specific objects (animals, monsters, ghosts)	—	Specific phobias
		Fear of germs or of getting a serious illness	—	Obsessive–compulsive disorder (OCD)
		Fear of natural disasters, fear of traumatic events (e.g., getting burned, being hit by a car or truck)	—	Specific phobias (natural environment), acute stress disorder, post-traumatic stress disorder, generalized anxiety disorder
	5–11 years	School anxiety, performance anxiety, physical appearance, social concerns	Withdrawal, timidity, extreme shyness with unfamiliar adults and peers, feelings of shame	Social anxiety disorder (social phobia)
Adolescence	12–18 years	Personal relations, rejection from peers, personal appearance, future, natural disasters, safety	Fear of negative evaluation	Social anxiety disorder (social phobia)

All children experience some fear, anxiety, and worry as a normal part of growing up.

Normal Anxieties

Like fears, anxieties are very common during childhood and adolescence. Various types of anxiety are evident by age 4 (Eley, Lichenstein, & Moffitt, 2003), and about 25% of parents report that their child is too nervous, fearful, or anxious (Achenbach, 1991a). The most frequent symptoms in samples of children with normal anxieties are separation anxiety, test anxiety, overconcern about competence, excessive need for reassurance, and anxiety about harm to a parent (Barrios & Hartmann, 1997).

   Younger children generally experience more anxiety symptoms than do older children, primarily about separation from parents. Girls display more anxiety than boys, but they generally experience similar types of symptoms. Although some specific anxieties decrease with age, such as separation anxiety and anxiety about school, nervous and anxious symptoms may not show the age-related decline observed for many specific fears (Hale et al., 2008). Anxious symptoms may reflect a stable trait that predisposes children to develop excessive fears related to their stage of development. Thus, the disposition to be anxious may remain stable over time, even though the objects of children's fears change.

Normal Worries

If worrying about the future is so unproductive, why do we do so much of it? part of the reason seems to be that the process of worry—thinking about all possible negative outcomes—serves an extremely useful function in normal development. In moderate doses, worry can help children prepare for the future—for example, by checking their homework before they hand it in or by rehearsing for an upcoming class play. Worry is a central feature of anxiety, and anxiety is related to the number of children's worries and to their intensity (Silverman, La Greca, & Wasserstein, 1995). Children of all ages worry, but the forms and expressions change. Older children report a greater variety and complexity of worries and are better able to describe them than are younger children (Chorpita et al., 1997).

Normal Rituals and Repetitive Behavior

Ritualistic, repetitive activity is extremely common in young children (Peleg-Popko & Dar, 2003). A familiar example is the bedtime ritual of saying good night—addressing people in a certain order or giving a certain number of hugs and kisses. Normal ritualistic behaviors in young children include preferences for sameness in the environment (e.g., watching the same DVD over and over again), rigid likes and dislikes, preferences for symmetry (e.g., carrying a toy in each hand), awareness of minute details or imperfections in toys or clothes (e.g., being bothered by a minuscule thread on a jacket sleeve), and arranging things so they are “just right” (e.g., insisting that different foods not touch each other on the plate). Rituals help young children gain control and mastery over their social and physical environments and make their world more predictable and safer (Evans et al., 1997). Any parent who has violated these rituals and paid the price can appreciate how important they are to the young child.

   Many common routines of young children fall into two distinct categories: repetitive behaviors and doing things “just right.” These categories are strikingly similar to those found for older individuals with OCD and related disorders, which we discuss later in the chapter. It is not known whether OCD is an extreme point on a continuum of normal developmental rituals or an entirely different problem (Evans, Gray, & Leckman, 1999). However, research suggests that the neuropsychological mechanisms underlying compulsive, ritualistic behavior in normal development and those in OCD may be similar (Pietrefesa & Evans, 2007).

Anxiety Disorders According to DSM-5

Anxiety disorders in DSM-5 are divided into seven categories that closely define the focus of the child's anxiety and the types of reaction and avoidance. To give you an overall picture, these disorders are described briefly in A Closer Look 11.1. The number of youths with multiple anxiety disorders increases with age. Keep in mind that significant associations exist between nearly all anxiety disorders. These associations are best explained by a model that

specifies multiple distinct anxiety syndromes that are related to a higher-order factor (e.g., negative affect) that is common to most if not all anxiety disorders, as well as depression (Higa-McMillan et al., 2014).

A CLOSER LOOK 11.1: Main Features of Seven DSM-5 Anxiety Disorders

Separation Anxiety Disorder (SAD)

Characterized by excessive worry regarding separation from home or parents. Youths may show signs of distress and physical symptoms on separation, experience unrealistic worries about harm to self or others when separated, and display an unwillingness to be alone.

Specific Phobia

Characterized by severe and unreasonable fears and avoidance of a specific object or situation, for example, dogs, spiders, darkness, or riding on a bus.

Social Anxiety Disorder (SOC) (Social Phobia)

Characterized by a severe and unreasonable fear of being embarrassed or humiliated when doing something in front of peers or adults.

Selective Mutism

Characterized by a consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., school), even though the child may speak loudly and frequently at home or in other settings.

Panic Disorder (PD)

Characterized by recurrent, unexpected and severe panic attacks. These attacks may consist of an accelerated heart rate, shortness of breath, sweating, upset stomach, dizziness, fear of dying, and others. The individual also experiences a persistent concern or worry about additional panic attacks or their consequences, or displays a significant maladaptive change in behavior to avoid having panic attacks (e.g., avoidance of exercise or new situations).

Agoraphobia

Characterized by fear or anxiety about two or more situations such as using public transportation, being in open spaces (e.g., parking lots, marketplaces), being in enclosed spaces (e.g., theaters), being in a crowd, or being outside of the home alone. The fear or anxiety about these situations occurs because the individual thinks that escape might be difficult or help not available if they were to develop panic-like or other incapacitating symptoms.

Generalized Anxiety Disorder (GAD)

Characterized by ongoing and excessive worry about many events and activities. Youths may worry about their grades in school, their relations with peers, and their own or others' safety. They may constantly seek comfort or approval from others to help reduce their worry.

Section Summary

   Description of Anxiety Disorders

· • Anxiety disorders are among the most common mental health problems in children and adolescents, but they often go unnoticed and untreated.

· • Anxiety is an adaptive emotion that prepares youngsters to cope with potentially threatening people, objects, or events. Strong negative emotions, physical tension, and apprehensive anticipation of future danger or misfortune characterize it.

· • The symptoms of anxiety are expressed through three interrelated response systems: physical, cognitive, and behavioral.

· • Fear is a present-oriented emotional reaction to current danger. In contrast, anxiety is a future-oriented emotion characterized by feelings of apprehension and a lack of control over upcoming events that might be threatening.

· • Fears, anxieties, worries, and rituals in children are common, change with age, and follow a predictable developmental pattern with respect to type.

· • DSM-5 specifies several types of anxiety and related disorders based on types of reaction and avoidance.

SEPARATION ANXIETY DISORDER

BRAD: “Don't Leave Me!”

Brad, age 9, is unable to enter any situation that requires separation from his parents—playing in the backyard, going to other children's homes, or staying with a babysitter. When forcibly separated from his parents, Brad cries or throws a full-blown tantrum. When his mother plans to leave the house, he runs through all the horrible things that might happen to her, in an endless series

of what-if questions. When she becomes frustrated and angry, Brad becomes even more anxious. The more anxious he gets, the more he argues with his mother, and the angrier she gets. Brad has also threatened to hurt himself if forced to go to school.

   Brad's separation problems began about a year ago, when his father was drinking too much and was frequently absent for long periods. Brad's problem gradually worsened over the course of the year, until he completely refused to go to school. Help was sought, but Brad continued to get worse. He developed significant depressive symptoms, including sadness, guilt about his problems, and occasional wishes to die.

Adapted from Last, 1988.

Separation anxiety is important for the young child's survival and is normal at certain ages. From about age 7 months through the preschool years, almost all children fuss when they are separated from their parents or others to whom they are close. In fact, a lack of separation anxiety at this age may suggest insecure attachment or other problems. Unfortunately, like Brad, some children continue to display such anxiety long after the age at which it is typical or expected. When anxiety persists for at least 4 weeks and is severe enough to interfere with normal daily routines such as going to school or participating in recreational activities, the child may have a separation anxiety disorder. The DSM-5 criteria are presented in Table 11.3.

   Children with separation anxiety disorder (SAD) display age-inappropriate, excessive, and disabling distress related to separation from their parents or other major attachment figures and fear of being alone (Cooper-Vince et al., 2014). Young children with SAD may have vague feelings of anxiety or repeated nightmares about being kidnapped or killed or about the death of a parent. They frequently display excessive demands for parental attention by clinging to their parents and shadowing their every move. Often, they are reluctant to sleep separated from their parents, and they try to climb into their parents' bed at night or sleep on the floor just outside their parents' bedroom door (Allen et al., 2010). Older children with SAD may have difficulty being alone in a room during the day, sleeping alone even at home, running errands, going to school, or going to camp. They may also have specific fantasies of illness, accidents, kidnapping, or physical harm.

   Children with SAD fear new situations and may display physical symptoms. To avoid separation, they may fuss, cry, scream, or threaten suicide if the parent leaves (although serious suicide attempts are rare); physical symptoms may include rapid heartbeat, dizziness, headaches, stomachaches, and nausea. Not surprisingly, parents, especially mothers, become highly distressed. Over time, as we saw with Brad, children with SAD may become increasingly withdrawn, apathetic, and depressed, and are at risk for developing a variety of other anxiety disorders during adolescence (Lewinsohn et al., 2008).

TABLE 11.3 | Diagnostic Criteria for Separation Anxiety Disorder (SAD)

DSM-5 · (A) 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: · (1) Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures. · (2) Persistent or excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death. · (3) 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. · (4) Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation. · (5) Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings. · (6) Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure. · (7) Repeated nightmares involving the theme of separation. · (8) Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated. · · (B) The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults. · (C) The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning. · (D) The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive 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 befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder. · (E) criteria and Specify if should be deleted in their entirety. No substitutions for either.

Prevalence and Comorbidity

SAD is one of the two most common anxiety disorders to occur during childhood (the other is specific phobia), and it is found in about 4% to 10% of all children (Merikangas et al., 2010). It is common in both boys and girls, although it is more prevalent in girls. About two-thirds of children with SAD have another anxiety disorder, and about half develop a depressive disorder following the onset of SAD. They may also display specific fears of getting lost or of the dark. School reluctance or refusal is also quite common in older children with SAD (Albano, Chorpita, & Barlow, 2003).

Onset, Course, and Outcome

Of children referred for anxiety disorders, SAD has the earliest reported age at onset (7 to 8 years) and the youngest age at referral (Shear et al., 2006). SAD generally progresses from mild to severe. It may begin with harmless requests or with symptoms such as restless sleep or nightmares, which progress to the child sleeping nightly in his or her parents' bed. Similarly, school mornings may evoke physical symptoms and an occasional absence from school, which escalates into daily tantrums about leaving for school and outright refusal. The child may become increasingly concerned about the parents' daily routine and whereabouts (Albano et al., 2003).

   Often, SAD occurs after a child has experienced major stress, such as moving to a new neighborhood, entering a new school, death or illness in the family, or an extended vacation. Brad's SAD emerged after his father developed a problem with alcohol and subsequently left home. The symptoms of SAD may also fluctuate over the years as a function of stress and transitions in the child's life. Although they may lose friends as a result of their repeated refusal to participate in activities away from home, children with SAD are reasonably skilled socially and get along with others. However, their school performance may suffer as a result of frequent school absences. The child may require special assignments just to keep up; in extreme cases, they may have to repeat the school year (Albano et al., 2003).

   SAD persists into adulthood for more than one-third of children and adolescents. As adults, these individuals are more likely than others to experience relationship difficulties (e.g., never marry or become separated or divorced), other anxiety disorders and mental health problems (particularly panic disorder and depression), and functional impairment in their social and personal lives (Milrod et al., 2014; Shear et al., 2006).

   School reluctance and refusal are quite common in youngsters with SAD.

ERIC: Won't Go to School

Eric, age 12, was referred by a school psychologist and his parents for his intense school refusal behavior. On entering seventh grade and a new school, he began to experience a variety of negative symptoms, such as hyperventilation, anxiety, sad mood, and somatic symptoms. Although attendance was not a problem at first, by mid-September Eric began to report severe headaches on school mornings. School attendance then became intermittent. By late September, his aversion to school had worsened and he was staying at home on most days.

Adapted from Kearney, 1995.

School Reluctance and Refusal

Although starting school is exciting and enjoyable for most children, many are reluctant to go to school and—for a few—school may create so much fear and anxiety that they will not go. These children can become literally sick with worry, let minor physical symptoms keep them at home, or pretend to be ill. School refusal behavior is defined as the refusal to attend classes or difficulty remaining in school for an entire day. It includes youngsters who resist going to school in the morning but eventually attend, those who go to school but leave at some point during the day, those who attend with great dread that leads to future pleas for nonattendance, and those who miss the entire day (Kearney, 2007).

   School refusal is equally common in boys and girls, and it occurs most often between the ages of 5 and 11 years. Excessive and unreasonable fears of school usually first occur during preschool, kindergarten, or first grade and peak during the second grade. However, school refusal can occur at any time and may have a sudden onset at a later age, as happened with Eric. Children who refuse school may complain of a headache, upset stomach, or sore throat just before it's time to leave for school, then begin to “feel better” when permitted to stay at home, only to feel “sick” again the next morning. As the time for school draws near, the child may plead, cry, and refuse to leave the house and may even have a full-blown panic reaction. School refusal often follows a period at home during which the child has spent more time than usual with a parent (e.g., brief illness, holiday break, or summer vacation). At

other times, school refusal may follow a stressful event such as a change of schools (as happened with Eric), an accident, or the death of a relative or family pet.

   For many children, fear of school is really a fear of leaving their parents—separation anxiety. However, school reluctance and refusal can occur for many reasons (Kearney & Albano, 2004). Most children who refuse to go to school have average or above-average intelligence, suggesting that it is not a difficulty with academics that leads to this problem. A fear of school may be associated with submitting for the first time to authority and rules outside the home, being compared with unfamiliar children, and experiencing the threat of failure. Some children fear school because they are afraid of being ridiculed, teased, or bullied by other children or being criticized or disciplined by their teachers. In other cases, the child's fear may result from an excessive or irrational fear of being socially evaluated or embarrassed when having to recite in class or undress in front of unfamiliar people in a gym class. Eric was extremely anxious about meeting new people, being late for class, moving from class to class, taking classes involving public speaking, and participating in gym class. He refused to attend school mainly to escape being socially evaluated and, to a lesser extent, to gain attention from his parents (Kearney & Silverman, 1996).