ARTICLE

Separation Anxiety
Disorder in School-Age
Children: What Health
Care Providers Should
Know
Jerrica Vaughan, MSN, RN, CPNP-PC,
Jennifer A. Coddington, DNP, MSN, RN, CPNP,
Azza H. Ahmed, DNSc, RN, IBCLC, CPNP, &
MaryLou Ertel, MS, BSN, RN, CPNP-PC

ABSTRACT untreated, can cause social and academic decline. Pediatric

Separation anxiety disorder (SAD) is the most common child- providers routinely see children in the primary care office
hood anxiety disorder, and it has many consequences, partic- and have the unique opportunity to diagnose, treat, and
ularly for school-age children. These consequences include manage children with SAD. Despite this, SAD continues to
excessive worry, sleep problems, distress in social and aca- be underdiagnosed and undertreated because of a gap in
demic settings, and a variety of physical symptoms that, left the literature regarding evidence-based practice guidelines
for pediatric providers. The purpose of this article is to
discuss the diagnosis and management of SAD in school-
Jerrica Vaughan, Certified Pediatric Nurse Practitioner, Purdue age children and highlight the role of pediatric providers in
University, West Lafayette, IN. managing separation anxiety. J Pediatr Health Care. (2017)
Jennifer A. Coddington, Clinical Associate Professor, Director of 31, 433-440.
the Pediatric Nurse Practitioner Master’s Program, Director of
Practice and Outreach, and Medical Director of North Central KEY WORDS
Nursing Clinics, Purdue University, West Lafayette, IN.
Pediatrics, separation anxiety disorder, school-age
Azza H. Ahmed, Associate Professor, School of Nursing, College
of Health and Human Sciences, Purdue University, West
Lafayette, IN.
Anxiety conditions including generalized anxiety
disorder, social anxiety and phobias, separation anxiety
MaryLou Ertel, Certified Pediatric Nurse Practitioner, Indiana
disorder (SAD), and posttraumatic stress disorder are
University Arnett, Lafayette, IN.
the most common mental health disorders in children.
Conflicts of interest: None to report. SAD is the most common childhood anxiety disorder
Correspondence: Jennifer A. Coddington DNP, MSN, RN, and occurs at a mean age of 7 years (Herren,
CPNP, 502 North University St, West Lafayette, IN 47907; In-Albon, & Schneider, 2013). Some anxiety in children
e-mail: [email protected].
is expected, making it difficult to recognize when the
0891-5245/$36.00 level of anxiety becomes a psychological problem or
Copyright Q 2016 by the National Association of Pediatric a disorder. Separation anxiety is developmentally
Nurse Practitioners. Published by Elsevier Inc. All rights normal for infants and toddlers but becomes a disorder
reserved. when it continues past toddlerhood. This article focuses
Published online December 21, 2016. on school-age children defined by the National Insti-
http://dx.doi.org/10.1016/j.pedhc.2016.11.003 tutes of Health as children ages 6 to 12 years

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(Kliegman, Stanton, Geme, Schor, & Behrman, 2015). 3 years old, and as the child continues to develop cogni-
There also appears to be underdiagnosing of SAD in tively, so does the ability to cope with separation anxi-
school-age children, which leads to children being un- ety, because the child learns that the caregiver will
dertreated. return (Milrod et al., 2014).
There are multiple epidemiologic reports on the Some children will develop excessive fear and anxiety
prevalence of SAD, but it is estimated that between when separated from their caregivers, leading to SAD.
1.09% and 4.1% of children ages 5 through 11 years The Diagnostic and Statistical Manual of Mental Disor-
have SAD (Lavallee et al., 2011). Another source esti- ders, 5th edition (American Psychiatric Association
mates that between 2% and 13% of children have SAD [APA], 2013), defines the criteria for separation anxiety
(Scaini, Ogliari, Eley, Zavos, & Battaglia, 2012). The var- as developmentally inappropriate and excessive fear
iations in prevalence rates may be accredited to a vari- or anxiety concerning separation from those to whom
ety of assessment methods and lack of reporting. the individual is attached. This excessive fear or worry
SAD leads to disturbances for both the child and the must cause significant impairment in social, academic,
caregiver that include excessive worry, sleep problems, or occupational areas of functioning, as well as last
distress in social and academic settings, and a variety of longer than 4 weeks to be considered SAD (Box 1).
physical symptoms (Brand et al., 2011). These distur-
bances, if not treated, can lead to further psychological
problems in adulthood. Furthermore, school-age chil- RISK FACTORS
dren who suffer from SAD may have consequences Several risk factors contribute to the development of
such as poor academic performance, social isolation, SAD. School-age children at higher risk for developing
and difficulty in social settings. There are several studies SAD include children with parents with panic disorder
that discuss different as- or other anxiety disorders (Lavallee et al., 2011).
pects of SAD, but there School-age Lavallee et al. (2011) also identify pregnancy and birth
is a gap in the literature children who suffer factors such as maternal smoking, alcohol consump-
regarding evidence-based tion, and low birth weight as factors that may increase
from SAD may have
practice guidelines for the risks of developing mental health problems in chil-
pediatric providers. The consequences dren. Therefore, family history and birth history are
purpose of this article such as poor important aspects to consider when evaluating a child
is to discuss the diag- for SAD. Scaini et al. (2012) suggest that there are also
academic
nosis and management genetic and environmental factors that significantly in-
of SAD in school-age performance, crease the risks of developing SAD. Some children may
children and to high- social isolation, and have an inborn anxious propensity, which may inher-
light the role of pediatric ently lead to SAD (Milrod et al., 2014). Environmental
difficulty in social
providers in managing factors and life circumstances that may contribute to
separation anxiety. settings. the development of SAD include divorce, military
leaves such as parental deployments during war, foster
BACKGROUND care, adoption, incarceration, parental death, and relo-
The National Institutes of Health (2014, p. 1) define sep- cation due to occupation. Khadar, Babapour, &
aration anxiety in children as ‘‘a developmental stage Sabourimoghaddam (2013) further expand on environ-
during which the child experiences anxiety when sepa- mental factors by identifying that 14% of children of
rated from the primary caregiver.’’ John Bowlby was alcoholic parents will develop SAD. Scaini et al.
one of the first theorists to discuss the relationships be- (2012) also conclude that girls are at higher risk, which
tween parents and children. Bowlby developed the may be due to internalization of emotions. Lavallee
attachment theory, in which he states that children et al. (2011) propose that the process of developing
who form an enduring social–emotional relationship SAD is influenced over time by cognitive maturation,
are more likely to survive (Kail, 2015). These relation- developmental and traumatic events, parenting style,
ships are formed very early and are usually with the and relationships with others. Anxiety-provoking care-
mother, but they can be formed with any responsive taking such as having a parent who is anxious has also
and caring person such as a father, grandparent, or been shown to affect SAD (Milrod et al., 2014). A study
other caregiver. Bowlby further described attachment by Jansen et al. (2011) suggests that children whose par-
as developing in four stages: preattachment, attach- ents stayed with them during the onset of sleep, such as
ment in the making, true attachment, and reciprocal re- co-sleeping, were at an increased risk of developing
lationships (Kail, 2015). At around 6 to 8 months of age, anxiety or depressive symptoms. It is also important
an infant has formed a secure relationship with his/her to note that school-age children have yet to develop
caregiver and also begins to experience distress when the verbal or cognitive skills needed to express their
separation from this caregiver occurs. Separation anxi- feelings and emotions (Allen, Blatter-Meunier,
ety is a normal part of development in children 1 to Ursprung, & Schneider, 2010).

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BOX 1. Diagnostic and Statistical Manual of Mental Disorders–V diagnostic criteria: Separation anxiety
disorder

1. 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:
(a) Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment
figures.
(b) Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as
illness, injury, disasters, or death.
(c) 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.
(d) Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of
separation.
(e) Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in
other settings.
(f) Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment
figure.
(g) Repeated nightmares involving the theme of separation.
(h) Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation
from major attachment figures occurs or is anticipated.
2. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months
or more in adults.
3. The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important
areas of functioning.
4. The disturbance is not better explained by another mental disorder, such as refusing to leave home because of exces-
sive 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 befall-
ing significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, (DSM-5Ò). American Psychiatric Pub.
Retrieved from http://dsm.psychiatryonline.org.ezproxy.lib.purdue.edu/doi/full/10.1176/appi.books.9780890425596.dsm05#BABBCCGJ
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright q2013). American Psy-
chiatric Association. All Rights Reserved.

CONSEQUENCES OF SAD FOR CHILDREN CONSEQUENCES OF SAD FOR THE CAREGIVER

There are many documented consequences for chil- SAD also causes high strain and difficulties for the
dren with SAD. Children with SAD may experience caregiver because of the child’s reluctance to be
social withdrawal, apathy, sadness, or difficulty separated (Brand et al., 2011). This high strain
concentrating on work or play, which in turn leads may cause frustration and resentment and may
to academic social difficulties (APA, 2013). Particular significantly affect the relationship between the child
consequences of SAD for school-age children include and caregiver. Parents and caregivers of children
school refusal, which often leads to poor academic with SAD often have lower parenting self-efficacy
achievement and social isolation (APA, 2013). Phys- (Herren et al., 2013). Other family members, such
ical symptoms associated with SAD include as siblings, may also become frustrated from the
headaches, abdominal symptoms such as nausea excessive needs of the child with SAD, which can
or vomiting, heart palpitations, and dizziness lead to resentment (APA, 2013).
(APA, 2013).
Evidence has shown that SAD precedes many
different psychiatric disorders including panic disorder PROVIDER ROLE IN MANAGING SEPARATION
with agoraphobia, social phobias, obsessive–compul- ANXIETY
sive disorder, bipolar disorder, pain disorder, depres- Pediatric providers have a unique role in being able
sive disorders, and alcohol dependence in to evaluate children and families routinely, and they
adolescence and adulthood (Brand et al., 2011). In are capable of intervening when there are physical
fact, Milrod et al. (2014) suggest that 75% of adults or psychological issues that arise in development.
with anxiety disorders had SAD as a child. SAD is also It is crucial that these providers have the knowledge
known as a specific risk factor for adult panic disorder and resources available to properly assess, diagnose,
(Kossowsky, Wilhelm, Roth, & Schneider, 2012). and offer treatment or referrals for SAD treatment.

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History Assessment
To effectively diagnose SAD in children, the provider BOX 2. History-taking questions
must complete a thorough history when children
and/or parents present with symptoms or concerns Questions for child
of separation anxiety. It is also important to include 1. What worries you?
2. Do you ever worry about something bad happening
SAD as a differential diagnosis when children present
to your mom or dad?
with somatic symptoms that have an unknown cause. 3. Do you ever sleep over at a friend’s or other family
Although some children may present with school member’s house?
refusal, many children with anxiety disorders present 4. Do you have bad dreams?
to a primary care provider with somatic complaints 5. Do you enjoy going to school?
such as headaches, stomachaches, chest pain, or other Questions for parent/caregiver
symptoms. A thorough history and physical examina- 1. What seems to worry your child?
tion should focus on physical differentials such as 2. How does your child act when you leave him/her?
appendicitis and migraines but also on psychological 3. How were the first few months of his/her life? Did
differentials such as SAD. Provider concerns with you bond well?
the history may indicate a further need for testing 4. What was your child’s temperament as a child?
(happy, fussy)
for SAD. Box 2 identifies examples of history questions
5. Does your child have a close attachment to another
that providers may use to help with the diagnosis of caregiver or close contact?
SAD (APA, 2013; In- 6. Does your child talk about bad things happening to
Albon et al., 2013). Although some you or another caregiver? (e.g., death)
Children with SAD children may 7. How does your child sleep? Does he/she sleep
often present with alone?
comorbid conditions present with school 8. Does your child have nightmares or repeated bad
such as depression refusal, many dreams that involve separation?
and attention deficit 9. Does your child do well in school? Does he/she fear
children with leaving you to go to school?
hyperactivity disorder,
and thus it is impor- anxiety disorders 10. What physical symptoms (if any) does your child
present to a primary have when he/she separates from you (e.g. head-
tant to consider these
aches, nausea, stomachaches)?
comorbid disorders care provider with 11. How long has this fear of separation occurred?
when screening for
and diagnosing SAD. somatic Sources: APA (2013) and In-Albon, Meyer, & Schneider (2013).
complaints.
Signs and
Symptoms
Signs and symptoms of SAD vary among children experience physical symptoms while at school,
and can be situational. These symptoms must inter- which can lead to poor concentration and a decline
fere with everyday activities to be considered SAD in academic success (Waite & Creswell, 2014).
(APA, 2013). Typical presentation of SAD includes
any separation-related stress such as getting nervous Screening and Diagnostics
if a caregiver is going to leave, worrying about There are several screening tools that are available to
something bad happening to the caregiver, worrying assess anxiety in children. Only one, the Separation
about being lost or kidnapped, fearfulness of being Anxiety Avoidance Inventory (SAAI), is specifically
places without a caregiver, fear of sleeping away designed to aid in the diagnosis of SAD. This tool as-
from the caregiver, or fearfulness of being left at sesses the degree to which a child avoids 12 separa-
home alone (Khadar et al., 2013). Other common tion situations and has a child and parent version
symptoms reported with SAD include avoidance of (In-Albon et al., 2013). Cronbach’s a reliability is be-
being alone or without a caregiver, refusal to go tween 0.81 and 0.84 for both the child and parents,
to school, bed wetting, and nightmares (Allen and test–retest reliability ranges from 0.80 and 0.82
et al., 2010). Those children may also present with (In-Albon et al., 2013). In-Albon et al. (2013) also
somatic symptoms such as headaches, stomachache, illustrate that convergent validity is high, which they
nausea, or vomiting when separation from a major support by strong correlations between child and
attachment figure occurs (Allen et al., 2010). parent measures of the SAAI (r = 0.35). There are a
School-age children in particular may have fears of few other common tools used to evaluate for other
being separated from their caregiver while at school, types of anxiety. Because many anxiety disorders
which can lead to school avoidance, poor academic have similar characteristics in children, these other
performance, and poor social interactions with peers tools, such as the Screen for Child Anxiety Related
(Allen et al., 2010). Those children with SAD may Emotional Disorders (SCARED), can be helpful to

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 TABLE 1. Screening and diagnostic tools
Age Length of
range, administration,
Screening tool Brief description How to obtain years minutes Cost
Beck Anxiety Inventory A 20-item, self-report inventory that
http://www.pearsonclinical. 7–18 5 $35 for
for Youth allows for early identification ofcom/psychology/products/ 1-year
symptoms of anxiety in children 100000153/beck-youth- subscription
and adolescents ages 7–14 years inventories-second-edition
-byi-ii.html
Screen for Child Anxiety A 41-item questionnaire administered http://www.pediatricbipolar. 8–18 10 Free
Related Emotional to children to assess five domains pitt.edu/content.asp?
Disorders (SCARED)– of anxiety id=2333#3304
Child Version
Screen for Child Anxiety A 41-item questionnaire administered http://www.pediatricbipolar. Parents 10 Free
Related Emotional to parents to assess five domains pitt.edu/content.asp?
Disorders (SCARED)– of anxiety id=2333#3304
Parent Version
Separation Anxiety Assesses the degree to which the http://link.springer.com/ 4–18 5 $39.95
Avoidance Inventory child avoids 12 separation article/10.1007%2Fs
for Children (SAAI-C) situations 10578-013-0364-z
Separation Anxiety Assesses the parent’s view of the http://link.springer.com/ Parents 5 $39.95
Avoidance Inventory degree to which child avoids article/10.1007%2Fs
for Parents (SAAI-P) 12 separation situations 10578-013-0364-z
Spence Children’s A 44-item questionnaire administered http://www.scaswebsite. 3–18 10 Free
Anxiety Scale–Child to children to assess the severity com/index.php?p=1_6
Version & Preschool of six domains of anxiety
Version
Spence Children’s A 44-item questionnaire administered http://www.scaswebsite. Parents 10 Free
Anxiety Scale–Parent to parents to assess the severity com/index.php?p=1_15
Version of six domains of anxiety
Revised Child Anxiety A 47-item, youth self-report http://www.childfirst.ucla. 8–18 15 Free
and Depression questionnaire that measures five edu/Resources.html
Scale (RCADS) anxiety subscales and major
depressive disorder
Revised Child Anxiety A 47-item questionnaire administered http://www.childfirst.ucla. Parents 15 Free
and Depression to parents that measures five edu/Resources.html
Scale Parent Version anxiety subscales and major
(RCADS-P) depressive disorder

assess other domains of anxiety. These screening all children with SAD (Brewer & Sarvet, 2011). When
tools, outlined in Table 1, can be administered to par- CBT alone is not sufficient to treat children with SAD,
ents and/or children. One downfall of these screening a combination therapy should be explored. The child/
tools is that they can be difficult to administer in adolescent anxiety multimodal study is a randomized
younger children, who have not developed the verbal clinical trial that looked at the efficacy of a CBT and ser-
and cognitive skills needed to accurately report symp- traline (Rapp et al., 2013). This study concluded that
toms (Allen et al., 2010). Another barrier to providers combination therapy of both CBT and sertraline (an
administering these tools is that each takes an average SSRI) resulted in significant improvement of anxiety
of 5 to 10 minutes to complete. However, these symptoms (Rapp et al., 2013). Therefore, children with
screening tools, along with a thorough history and SAD ages 6 years and older are best treated with a com-
evaluation, can aid in the diagnosis of SAD. bination of an SSRI and CBT when both are available
(Mohatt, Bennett, & Walkup, 2014). There are not any
MANAGEMENT medications approved for children younger than 6 years
SADs in pediatrics can be treated with psychological, of age, so those younger than 6 years should be treated
behavioral, and pharmacologic interventions. There with CBT alone.
have been multiple studies that look at the efficacy of
these treatments, and current recommendations include Psychotherapeutic
the use of cognitive behavioral therapy (CBT) and selec- There are multiple techniques that can be used to
tive serotonin reuptake inhibitors (SSRIs; Rapp, Dodds, help children with SAD develop coping strategies,
Walkup, & Rynn, 2013). CBT is the first-line treatment for and these techniques are generally used as

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first-line treatment for mild to moderate SAD decrease in depressive or anxiety symptoms. A ran-
(Brewer & Sarvet, 2011). For example, a study con- domized controlled trial found that children who
ducted by Khadar et al. (2013) implemented an art received 12 weeks of fluoxetine showed a greater
therapy program to elementary school boys with response rate than those that received a placebo
SAD in which each participant went through 24 ses- (Brewer & Sarvet, 2011).
sions of painting therapy. The findings showed that Although pharmacologic therapy can be very
the boys with SAD developed more adaptive behav- beneficial, it does not come without risks and there-
iors and emotions, and the children tended to share fore should be used cautiously. There are many
more feelings and improved their communication adverse effects associated with SSRIs including
skills (Khadar et al., 2013). There are also many pro- insomnia, vomiting, reduced or increased appetite,
grams that have been developed using CBT. Rapp and fatigue (Mohatt et al., 2014). There is also a
et al. (2013) highlighted Camp Cope-A-Lot and black box warning for increased risk for suicidal
BRAVE-ONLINE as two computer-assisted programs ideation with the use of SSRIs. Therefore, it
designed to implement CBT in children with anxiety is important for providers to closely monitor all pa-
disorders. These programs have been shown to be tients for changes in behavior or suicidality, espe-
very effective in helping children with SAD. In cially in the first 1 to 2 months of therapy;
fact, Camp Cope-A-Lot in studies has reduced symp- caregivers are instructed to closely monitor the
toms in patients, and 8% of participants no longer child, and appropriate documentation is included
met diagnosis criteria (Rapp et al., 2013). These, as in the child’s chart (Taketomo et al., 2015). Further-
well as other varieties of CBT, are usually imple- more, SSRIs do not reach maximum effect until 4 to
mented by social workers and therapists, and there- 6 weeks of treatment (Taketomo et al., 2015). Chil-
fore it is critical that the pediatric provider refers the dren who are prescribed SSRIs should seen weekly
child to psychotherapy. for the first month of treatment, biweekly for the
second month, and at least at 12-week intervals af-
Pharmacologic ter to monitor for risk of suicide, adverse effects,
Pharmacologic therapies are generally a second-line and effectiveness (Taketomo et al., 2015). SSRIs
treatment used in conjunction with CBT in children should be continued at least 6 months past the
with mild to moderate SAD (Brewer & Sarvet, 2011). initial period of response and then may gradually
Selective serotonin reuptake inhibitors are the medi- be discontinued (Taketomo et al., 2015).
cation of choice in the treatment of moderate to se- There have been very few trials that look at the ef-
vere anxiety disorders in children when CBT alone ficacy and safety of using other medications such as
has been insufficient (Brewer & Sarvet, 2011). SSRIs serotonin–norepinephrine reuptake inhibitors or
work by inhibiting the central nervous system’s re- other antidepressants in childhood anxiety, and
uptake of the neurotransmitter serotonin, which is therefore they are not generally recommended
involved in regulating mood (Taketomo, Hodding, (Mohatt et al., 2014). Benzodiazepines such as clo-
& Kraus, 2015). This leads to an increase in the avail- nazepam and alprazolam that are frequently used to
ability of serotonin at the synaptic cleft and, thus, a treat anxiety in adults are not approved for children

TABLE 2. Common medications

Medication Adverse effects Dosing for SAD
Fluoxetine Anorexia, diarrhea, constipation, thirst, weight gain, Children 7–11 years: oral, 5 mg/dose or 0.25 mg/kg/dose
weight loss, heart palpitations, abnormal dreams, once daily
agitation, dizziness, headache, insomnia, pruritus, rash
Sertraline Heart palpitations, dizziness, aggressive behavior, Children 6–12 years: 12.5–25 mg once daily, may titrate
drowsiness, fatigue, headache, insomnia, weight gain, dosage by 25–50 mg/day if clinically needed
constipation, diarrhea, dyspepsia, nausea, vomiting,
purpura, back pain, myalgia, hyperkinesia, epistaxis,
fever, sinusitis
Paroxetine Chest pain, heart palpitations, tachycardia, abnormal Children and adolescents 8–17 years: 10 mg once daily,
dreams, amnesia, dizziness, drowsiness, emotional may titrate in 10 mg/day with a maximum dose of
lability, fatigue, headache, lack of concentration, 50 mg/day
myasthenia, nervousness, weight gain, constipation,
diarrhea, dyspepsia, back pain, weakness, tremor,
blurred vision, dyspnea, pharyngitis
Source: Taketomo et al., (2015).

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and should not be used to treat SAD. The most com- positive reinforcement in the form of the caregiver’s
mon medications used to treat SAD are summarized accommodation of child anxiety symptoms and
in Table 2. external negative reinforcement such as support of
avoidance behavior (allowing the child to stay
EDUCATION FOR PARENTS home from school) often lead to greater symptom
Educating parents is essential to the school-age severity (Mohatt et al., 2014). Some resources for
children’s success when diagnosed with parents are highlighted in Table 3 (Brewer &
SAD. Caregivers often struggle to understand the Sarvet, 2011).
proper way to deal with children with SAD. Some
parents also need help in managing their own anx- IMPLICATIONS FOR PRACTICE
iety, which can be contributing to the child’s anxi- SAD can effectively be managed in school-age children
ety. The pediatric provider can provide resources with a variety of treatment options including CBT and
and tools to parents to help in the management pharmacologic therapy. Pediatric providers are at the
of SAD. These tools can help educate parents on forefront of diagnosing and initiating treatment for
techniques to help their children develop coping these children. Once at-risk patients for SAD are identi-
skills and ways to stay calm (Brewer & Sarvet, fied and a thorough history is obtained, the pediatric
2011). For example, deep breathing, progressive provider should administer a screening tool to further
muscle relaxation, and visualization exercises can help determine a diagnosis of SAD. Once a diagnosis
be quickly taught to parents that they can use to is made, the pediatric provider needs to initiate treat-
reduce somatic symptoms when a child is ment. As mentioned, CBT is the first-line treatment for
experiencing anxiety treating mild to moderate SAD, and it is the only treat-
(Brewer & Sarvet, Caregivers often ment currently available for children younger than
2011). Caregivers of struggle to 6 years of age (Brewer & Sarvet, 2011). A referral to a
children with SAD therapist may be necessary, because most pediatric
who are started on
understand the providers do not have appropriate training in CBT
pharmacologic treat- proper way to deal and do not have enough time to effectively implement
ments should be with children with CBT in the office. If CBT alone does not result in signif-
edu-cated on the risk icant improvement in symptoms, pharmacologic ther-
for increased suicidal
SAD. apy with the use of an SSRI should be initiated along
ideation, potential with CBT (Brewer & Sarvet, 2011). For children who
adverse effects, duration for expected improvement are not responsive to CBT and an SSRI, a referral to a
in symptoms, and treatment length (Taketomo psychiatrist would be warranted. Because many chil-
et al., 2015). dren with SAD have caregivers with anxiety or depres-
Caregivers also need to be educated and highly sion, the pediatric provider should also screen for
involved in CBT. Mohatt et al. (2014) state that fam- caregiver depression or anxiety and refer the caregiver
ily members need to understand the positive and for treatment if necessary (Kliegman et al., 2015). It is
negative reinforcement patterns that affect the important to mention that although somatic complaints
child’s anxiety symptoms. For example, external may in fact be related to anxiety, even once an anxiety

TABLE 3. Resources for parents

Resource Brief description
Helping Your Anxious Child: A Step-By-Step Guide for Parents by A cognitive behavioral therapy workbook for parents
Ronald Rapee and Ann Wignall
Worried No More: Help and Hope for Anxious Children Second Offers specific how-to cognitive behavioral strategies for parents
Edition by Aureen Pinto Wagner and school and health care professionals.
Make Your Worrier a Warrior: A Guide to Conquering your Child’s Offers practical approaches for parents to help with the child’s
Fears by Daniel Peters anxiety
Anxiety-Free Kids: An Interactive Guide for Parents and Children by Interactive workbook for parents and children to help achieve
Bonnie Zucker relaxation in children who are anxious
Growing Up Brave: Expert Strategies for Helping Your Child Outlines effective and convenient parenting techniques for reducing
Overcome Fear, Stress, and Anxiety by Donna Pincus anxiety in children
Anxious Kids, Anxious Parents: 7 Ways to Stop the Worry Cycle and Offers exercises and techniques to change both the children’s and
Raise Courageous and Independent Children by Reid Wilson parents’ patterns of thinking and behaving
The Opposite of Worry: The Playful Parenting Approach to Highlights effective strategies to combat anxiety using fun and play
Childhood Anxieties and Fears by Lawrence Cohen techniques
Source: Brewer & Sarvet (2011).

www.jpedhc.org July/August 2017 439

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disorder is diagnosed, the provider has a responsibility Herren, C., In-Albon, T., & Schneider, S. (2013). Beliefs regarding
to make sure that new somatic problems or diagnoses child anxiety and parenting competence in parents of children
with separation anxiety disorder. Journal of Behavior Therapy
are not ignored. If a child does not respond to the rec- and Experimental Psychiatry, 44(1), 53-60.
ommended treatment, alternative diagnoses should In-Albon, T., Meyer, A. H., & Schneider, S. (2013). Separation Anx-
be considered. It is also important for the provider to iety Avoidance Inventory–Child and Parent Version: Psycho-
work with the child’s school to develop a plan to transi- metric properties and clinical utility in a clinical and school
tion a child with SAD back to school in a timely manner. sample. Child Psychiatry & Human Development, 44(6),
689-697.
This may include collaborating with the school nurse, Jansen, P. W., Saridjan, N. S., Hofman, A., Jaddoe, V. W., Verhulst,
principal, counselor, teachers, and bus driver to help F. C., & Tiemeier, H. (2011). Does disturbed sleeping precede
the child avoid lengthy absences from school. symptoms of anxiety or depression in toddlers? The generation
R study. Psychosomatic Medicine, 73(3), 242-249.
CONCLUSION Kail, R. (2015). Children and their development (7th edn). Saddle
River, NJ: Prentice Hall.
SAD is a common condition that is underdiagnosed, can Khadar, M. G., Babapour, J., & Sabourimoghaddam, H. (2013). The
be debilitating, and has many consequences for the effect of art therapy based on painting therapy in reducing
school-age child. Pediatric providers have the unique symptoms of separation anxiety disorder (SAD) in elementary
ability of routinely seeing children, and those who are school boys. Procedia-Social and Behavioral Sciences, 84,
familiar with SAD are able to recognize the symptoms 1697-1703.
Kliegman, R. M., Stanton, B., Geme, J. S., Schor, N. F., & Behrman,
that interfere with the everyday life of children suffering R. E. (2015). Nelson textbook of pediatrics. Philadelphia, PA:
from separation anxiety. Children with SAD often pre- Elsevier Health Sciences.
sent with somatic symptoms, and therefore, SAD Kossowsky, J., Wilhelm, F. H., Roth, W. T., & Schneider, S. (2012).
should be considered as a differential diagnosis when Separation anxiety disorder in children: disorder-specific re-
ruling out physical conditions for these somatic com- sponses to experimental separation from the mother. Journal
of Child Psychology and Psychiatry, 53(2), 178-187.
plaints. It is the role of the pediatric provider to initiate Lavallee, K., Herren, C., Blatter-Meunier, J., Adornetto, C., In-Albon,
treatment, either CBT or pharmacologic, to help chil- T., & Schneider, S. (2011). Early predictors of separation anxiety
dren manage SAD. Referrals to therapy in which chil- disorder: early stranger anxiety, parental pathology and prenatal
dren can receive CBT is a very important piece to Factors. Psychopathology, 44(6), 354.
managing SAD. It is also important for pediatric pro- Milrod, B., Markowitz, J. C., Gerber, A. J., Cyranowski, J., Altemus,
M., Shapiro, T., ., Glatt, C. (2014). Childhood separation anx-
viders to provide resources to parents and caregivers iety and the pathogenesis and treatment of adult anxiety. Amer-
to help manage their children’s anxiety. A priority ican Journal of Psychiatry, 171(1), 34-43.
goal is to ensure that children with SAD do not miss Mohatt, J., Bennett, S. M., & Walkup, J. T. (2014). Treatment of sep-
extensive amounts of school, and the provider must aration, generalized, and social anxiety disorders in youths. Per-
collaborate with school personnel when developing a spectives, 171(7), 741-748.
National Institutes of Health. (2014). Separation anxiety in children.
return-to-school plan for the child. Bethesda, MD: Author. Retrieved from http://www.nlm.nih.
gov/medlineplus/ency/article/001542.htm
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For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.