1 Chapter 8 1 Separation ~nxi+ Disorder WENDY K. SILVERMAN ANDREAS DICK-NIEDERHAUSER Separation anxiety disorder (SAD) is a common psychiatric disorder of childhood and early adolescence and is characterized by an unrealistic and excessive fear of separation from an attachment figure, usually the parent, which significantly interferes with daily activities and develop- mental tasks. Children and adolescents (hereafter referred to as children) with SAD are tremendously worried that harm may come to their par- ents or themselves when separated, so that they might never be reunited again. The range of emotional, cognitive, somatic, and behavioral symp- toms associated with the fear or threat of separation from an attachment figure cripples the child's enjoyment of life, his or her social and family relationships, and abilities to participate and progress in school and rec- reational and creative activities. Several studies have suggested that childhood SAD may be a risk factor for other anxiety disorders later in life (Keller et al., 1992; Last, Perrin, Hersen, & Kazdin, 1996; Moreau & Follet, 1993), but whether this link is specific to panic disorder and agoraphobia (Gittelman & Klein, 1984) or whether SAD represents a general factor of vulnerability for a broad range of anxiety disorders is still debated (Barlow, 2002; Silove & Manicavasagar, 2001). Separation anxiety has been studied as a characteristic of normal development and as a symptom for many years (Bowlby, 1973; Freud,8. Separation Anxiety Disorder 1 65 190911955). Bowlby's influential attachment theory emphasizes the sur- vival value of infants' proximity to their caretakers and of caregivers' ten- dency to behave reciprocally. When infants' proximity to their caretakers is inadequate (i.e., separation), an intense affective response is produced (sep- aration distress or anxiety). Normal separation distress usually intensifies during early childhood, then gradually subsides at 3 to 5 years of age (Kagan, Kearsley, & Zelazo, 1978). Separation anxiety became a distinct clinical diagnostic category with publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-111; American Psychiatric Association) in 1980. In accordance with the DSM, when children's separation anxieties persist be- yond the developmentally appropriate years, and if the anxieties cause sig- nificant distress or impairment in social, academic, family, or other impor- tant areas of youths' functioning, a specific psychological maladjustment as characterized by the diagnosis of SAD may be warranted. EPIDEMIOLOGY AND COMORBIDITY SAD is among the most common anxiety disorders in childhood. In a sam- ple of children referred to an anxiety disorders specialty clinic, SAD was the most prevalent disorder, with a rate of 33% (Last, Francis, Hersen, Kazdin, & Strauss, 1987). Different epidemiological studies indicate a prevalence of 3 to 5% in children and adolescents (Anderson, Williams, McGee, & Silva, 1987; Benjamin, Costello, & Warren, 1990; Bird et al., 1988; Bowen, Offord, & Boyle, 1990; Costello, 198913; Costello et al., 1988; Kashani et al., 1987; Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993; Prior, Sanson, Smart, & Oberklaid, 1999). The prevalence of reported SAD symptoms without significant impairment is much higher, with an estimate of up to 50% in 8-year-olds (Kashani & Orvaschel, 1990). Several studies have found an overrepresentation of girls with SAD (Anderson et al., 1987; Costello, 198913; Last, Francis, et al., 1987a), whereas other studies have reported equal frequency in girls and boys (Bird, Gould, Yager, Staghezza, & Canino, 1989; Francis, Last, & Strauss, 1987; Last, Perrin, Hersen, & Kazdin, 1992). Males and females seem to be indistinguishable in the expression of their SAD symptoms (Francis et al., 1987). Even though most children with anxiety disorders are from middle- to upper-middle-class families, 50 to 75% of children with SAD come from low- socioeconomic-status homes (Last et al., 1992; Last, Francis, et al., 1987; Velez, Johnson, & Cohen, 1989) and tend to be of lower socioeconomic status than children with overanxious and phobic disorders (primarily school avoidant; Last, Francis, et al., 1987). In addition, although the research is166 11. DISORDERS sparse, among children referred to anxiety disorders specialty clinics, rates of SAD have not been found to vary between European American and African American children (Last & Perrin, 1993) or between European American and Hispanic American children (Ginsburg & Silverman, 1996). Using a dimensional measure of anxiety, the Multidimensional Anxiety Scale for Children (MASC; March, Parker, Sullivan, Stallings, & Conners, 1997), sociodemographic variations have been found among community (N = 2,384; ages 8-19 years) and clinic (N = 227; ages 8-18 years) samples of children who report symptoms of SAD and social phobia (Compton, Nelson, & March, 2000). Children were divided into three age groups: 8- 12 years, 13-15 years, and 16-19 years. Children's responses to symptoms of separation anxiety and social phobia were classified according to whether they were above (high) or below (low) the mean score on the respective subscales. Results indicated that children from the community who reported a high number of symptoms of SAD and social phobia tended to be between 8 and 12 years of age and female. Children from the cornrnu- nity who reported a high number of SAD symptoms but minimal symptoms of social phobia also tended to be between 8 and 12 years of age and fe- male. Children from the community sample who reported a high number of social phobia symptoms only tended to be in middle adolescence (ages 13- 15 years old) and male. With respect to race, European American children reported a higher number of symptoms of social phobia than African American children; African American children reported a higher number of symptoms of SAD than European American children. Similar comparisons were conducted for the clinical sample (with the exception of race). Results indicated that children from the clinical sample who reported a high num- ber of both SAD and social phobia symptoms tended to be between 8 and 12 years old. In terms of gender, females reported more symptoms of both SAD and social