1. Separation Anxiety Disorder An Anxiety Disorder

2. Anxiety Disorders Separation Anxiety Disorder Separation Anxiety Disorder Selective Mutism Specific Phobia Social Anxiety Disorder (social phobia) Panic Disorder Agoraphobia Generalized Anxiety Disorder Substance/Medication-Induced Anxiety Disorder Anxiety Disorder Due to Another Medical Condition Other Specified Anxiety Disorder Unspecified Anxiety Disorder

3. Anxiety Disorders Similarities Differences

4. Introduced DSM-III, 1980 – 3 of 9 symptoms @ least 2 weeks – Anxiety Disorders of Childhood DSM-III to DSM-IV – 3 of 8 criteria @ least 4 weeks – No more Anxiety Disorders of Childhood IV to IV-TR – Prevalence and Course sections were updated IV-TR to DSM-5 – Anxiety Disorder – Wording – No more specific onset of 18yo – Addition of 6mo or more duration criterion History of Separation Anxiety Disorder in the DSM

5. Separation Anxiety Disorder: DSM-5 A. Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by at least three (or more) of the following:  (1) Recurrent excessive distress when separation from home or major attachment figures  (2) Persistent and 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)  (4) Persistent reluctance or refusal to go out, away from the home, to school, to work, or elsewhere because of fear of separation  (5) Persistently 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 Specify if: Early Onset: if onset occurs before age 6 years

6. A. Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by at least three (or more) of the following: A. Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by at least three (or more) of the following:  (1) Recurrent excessive distress when separation from home or major attachment figures  (2) Persistent and 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)  (4) Persistent reluctance or refusal to go out, away from the home, to school, to work, or elsewhere because of fear of separation  (5) Persistently 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 Criterion for Separation Anxiety Disorder

7. 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 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. 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 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 Specify if: Early Onset: if onset occurs before age 6 years Criterion for Major Depressive Disorder

8. Prevalence Little controlled research on SAD Prevalence rate of 2-4 % One study did report 2.8% [2.8%, 95% confidence interval (CI) 2.1-3.8, for current disorder] 15-35% prevalence rate in samples of children with anxiety disorders Suggestion that SAD occurs more frequently in girls but there is very little support Prevalence rate does NOT increase with age

9. Of youth who will develop SAD

10. Prevalence rate declines with age

11. Development, Onset, Course, Duration https://www.youtube.com/watch?v=jEkFp0Ux4OQ

12. Development, Onset, Course, Duration cont… Course is marked by exacerbation and remission over a period of years As many as 30-44% of children with SAD show evidence of psychological problems that continue into adult life May precede the development of conditions such as panic disorder and agoraphobia

13. Associated Features Behavioral Behavioral – Social withdrawal – Difficulty concentrating on work or play – Homesick and Uncomfortable – Anger or Aggression Emotional Emotional – Apathy – Sadness Physical Symptoms Physical Symptoms – Nausea/Vomiting – Headaches – Stomaches

14. Cognitive Cognitive – Evening or dark perceptual experiences – Fears Accidents Illness Monsters Of getting lost Of being kidnapped Associated Features cont.

15. What do children with Separation Anxiety Disorder look like? Demanding Demanding Intrusive Intrusive Frustration Frustration Resentment Resentment Conflict Conflict

16. Difference in expression between younger and older children Younger Children 5-8yo Younger Children 5-8yo – More symptoms – Unrealistic worry – School refusal Older Children 9-12yo Older Children 9-12yo – Excessive distress Adolescence Adolescence – Somatic complaints – School refusal more common

17. Risk of Subsequent Psychopathology

18. Models of Separation Anxiety Environmental Change Environmental Change Genetic Genetic Parent-Child Attachment Parent-Child Attachment Developmental Considerations Developmental Considerations Cognitive Factors Cognitive Factors Behavioral Factors Behavioral Factors Stress Factors Stress Factors

19. Environmental Change STRESS Separation Anxiety Disorder

20. Genetic Influence History of panic disorder, anxiety, or depression Predisposition toward later development of anxiety disorders

21. Parent-Child Attachment …Emotional distance Behaviors

22. Developmental Considerations Between and Within Slower rate of development can foster separation anxiety

23. Cognitive Factors Anxiety & Irrational Behaviors

24. Behavioral Factors Crying and Clinging Behavior = distract attention away Nurtures anxiety and fear

25. Stress Factors Change (stress factor) Feel uncomfortable Anxious Response

26. Neurobiology of Separation Anxiety Disorder Research done on the neurobiology of SAD has not been exclusively conducted on SAD. Literature has included SAD when analyzing all anxiety disorders in groups of children. They amygdala has been one of the most prominent structures identified as being involved in anxiety disorders. Until more research has been conducted solely on SAD any conclusions drawn would be an extrapolation of the findings from the other anxiety disorders

27. Accounting for Variance: Genetics Bolton D, Eley TC, O’Connor TG, et al. Twin pair study of 6-6.5yo N = 854 MZ and DZ

28. Accounting for Variance: Genetics cont.

29. Accounting for Variance: HPA-Axis

30. Accounting for Variance: HPA-Axis and hormonal influences during pregnancy Maternal endocrine activation during pregnancy and/or early separation or loss Lower cortisol levels Anxiety, learned helplessness, depression

31. Accounting for Variance: HPA-Axis and Cognitive Appraisal Cognitive processes may trigger the stimulation of the HPA axis activity Cognitive processes may trigger the stimulation of the HPA axis activity – The interpretation of a situation as being stressful or not – Separation anxiety disorder is derived from theories of anxiety disorders generally, which are predominately cognitive theories

32. Accounting for Variance: HPA-Axis and Cognitive Appraisal and Gender The pattern of results from the previous findings suggests there may be some gender- related differences with regard to the cognitive appraisal and anticipation of threat

33. Accounting for Variance: Family Dynamic Cronk, N. J., Slutske, W. S., Madden, P. a F., Bucholz, K. K., & Heath, A. C. (2004). Risk for separation anxiety disorder among girls: paternal absence, socioeconomic disadvantage, and genetic vulnerability. Journal of abnormal psychology, 113(2), 237–47. doi:10.1037/0021- 843X.113.2.237 N=1,887 Female MZ and DZ twin pairs Looking across 4 SAD Categories @ – Attachment – Paternal Absence – Socioeconomic Disadvantage

34. 4 Categories of SAD SAD-Symptoms SAD-Symptoms – Presence of 3 or more symptoms SAD-Cluster SAD-Cluster – Presence of 3 or more symptoms occuring together for a period of at least 1 month SAD-Impair SAD-Impair – Presence of 3 or more symptoms causing impairment in functioning and/or treatment seeking SAD-Full SAD-Full – Presence of 3 or more symptoms with clustering and impairment/treatment seeking, consistent with DSM-IV

35. Race Income Paternal Absence

37. a=additive genetic factor c=shared environmental factor p=paternal absence effect s=socioeconomic disadvantage effect

39. What this study says… Effects of paternal absence on SAD are rather robust. As predicted, paternal absence appears to be an important predictor of all categories of SAD – Suggesting that the loss or threat of loss of a father figure has important consequences for separation anxiety in girls. Attachment theory, suggest that the loss of a parent (or attachment figure) in the preschool years or younger would be most detrimental to subsequent development.

40. What this means… Socioeconomic disadvantage Socioeconomic disadvantage – 0.1%-1.0% total variance – 0.4%-2.7% shared environmental effects Paternal Absence Paternal Absence – 1.0%-3.0% total variance – 4.3%-8.7% shared environmental effects “Important role for genes” High Heritability estimates for parent- reported symptoms of SAD in girls

41. Maddie Marks’ Model

42. References

43. References cont.