# 35 - 31.13a Separation Anxiety Disorder, Generaliz

# 31.13a Separation Anxiety Disorder, Generalized Anxiety Disorder, and Social Anxiety Disorder (Social Phobia)

normative development in infants, anxiety disorders in childhood predict a wide range
of psychological difficulties in adolescence including additional anxiety disorders, panic
attacks, and depressive disorders. Fear is an expected response to real or perceived
threat; however, anxiety is the anticipation of future danger. Anxiety disorders are
characterized by recurrent emotional and physiological arousal in response to excessive
perceptions of perceived threat or danger. Anxiety disorders commonly found in youth
include separation anxiety disorder, generalized anxiety disorder, social anxiety
disorder, and selective mutism. Anxiety is classified into disorders based on how it is
experienced, the situations that trigger it, and the course that it tends to follow.
31.13a Separation Anxiety Disorder, Generalized Anxiety
Disorder, and Social Anxiety Disorder (Social Phobia)
Separation anxiety disorder, generalized anxiety disorder, and social anxiety disorder in
children are often considered together in the evaluation process and differential
diagnosis, and in developing treatment strategies, because they are highly comorbid and
have overlapping symptoms. A child with separation anxiety disorder, generalized
anxiety disorder, or social anxiety disorder has a 60 percent chance of having at least
one of the other two disorders as well. Of children with one of the above anxiety
disorders, 30 percent have all three of them. Children and adolescents may also have
additional comorbid anxiety disorders such as specific phobia or panic disorder.
Separation anxiety disorder, generalized anxiety disorder, and social anxiety disorder
are distinguished from each other by the types of situations that elicit the excessive
anxiety and avoidance behaviors.
SEPARATION ANXIETY DISORDER
Separation anxiety is a universal human developmental phenomenon emerging in
infants younger than 1 year of age and marking a child’s awareness of a separation
from his or her mother or primary caregiver. Normative separation anxiety peaks
between 9 months and 18 months and diminishes by about 2½ years of age, enabling
young children to develop a sense of comfort away from their parents in preschool.
Separation anxiety or stranger anxiety most likely evolved as a human response that
has survival value. The expression of transient separation anxiety is also normal in
young children entering school for the first time. Approximately 15 percent of young
children display intense and persistent fear, shyness, and social withdrawal when faced
with unfamiliar settings and people. Young children with this pattern of significant
behavioral inhibition are at higher risk for the development of separation anxiety
disorder, generalized anxiety disorder, and social phobia. Behaviorally inhibited
children, as a group, exhibit characteristic physiological traits, including higher than
average resting heart rates, higher morning cortisol levels than average, and low heart
rate variability. Separation anxiety disorder is diagnosed when developmentally

inappropriate and excessive anxiety emerges related to separation from the major
attachment figure. According to the American Psychiatric Association’s Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), separation anxiety disorder is
characterized by a level of fear or anxiety regarding separation from their parents or
primary caregiver, which is beyond developmental expectations. Furthermore, there
may be a pervasive worry that harm will come to a parent upon separation, which leads
to extreme distress, and sometimes nightmares. The DSM-5 requires the presence of at
least three symptoms related to excessive worry about separation from a major
attachment figure for a period of at least 4 weeks. The worries often take the form of
refusal to go to school, fears and distress on separation, repeated complaints of physical
symptoms such as headaches and stomachaches when separation is anticipated, and
nightmares related to separation issues.
GENERALIZED ANXIETY DISORDER
Children with generalized anxiety disorder have significant distress in activities of daily
life often focused on the child’s fears of incompetence in many areas, including school
performance and in social settings. In addition, children with generalized anxiety
disorder, according to DSM-5, experience at least one of the following symptoms:
restlessness, being easily fatigued, “mind going blank,” irritability, muscle tension, or
sleep disturbance. Children with generalized anxiety disorder tend to feel fearful in
multiple settings and expect more negative outcomes when faced with academic or
social challenges, compared with peers. Children and adolescents with generalized
anxiety disorder may experience symptoms of autonomic hyperarousal such as
tachycardia, shortness of breath, or dizziness, and are more likely than nonanxious
youth to experience sweating, nausea, or diarrhea when they become anxious. Children
and adolescents with generalized anxiety disorder tend to be overly concerned about
potential natural disasters such as earthquakes or floods, and these worries can interfere
with their daily activities. Finally, children and adolescents with generalized anxiety
disorder are continuously worried about the quality of their performance in academics,
sports, and other activities, and often seek excessive reassurance about their
performance.
SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA)
Children who experience intense discomfort and distress in social situations and are
impaired by their fear of scrutiny or humiliation are given the diagnosis of social
anxiety disorder. Their distress may be expressed in the form of crying, tantrums,
avoidance, freezing, or even becoming “mute” in these situations. According to DSM-5,
this disorder is characterized by consistent anxiety and distress in almost all social
situations. Any situation in which the child feels exposed to possible scrutiny by others
can provoke fear or anxiety, and the child will often try to avoid these feared social
situations. Children must experience the anxiety in the presence of peers, not only with
adults, in order to receive the diagnosis. A child or adolescent with social anxiety

disorder may exhibit the performance only type, which targets a specific type of
performing, such as fear of public speaking. The performance only type typically
manifests in school or academic settings in which public presentations must be
performed, such as in front of classmates in school.
Social anxiety disorder has significant implications for future accomplishments, since
it is associated with lower levels of satisfaction in leisure activities, increased rates of
school dropout, less productivity in the workplace as adults, and increased rates of
remaining single. Despite the significant impairment caused by social anxiety disorder,
up to half of individuals with the disorder do not receive treatment.
EPIDEMIOLOGY
The prevalence of anxiety disorders has varied with the age group of the children
surveyed and the diagnostic instruments used. Lifetime prevalence of any anxiety
disorder in children and adolescents ranges from 10 percent to 27 percent. Anxiety
disorders are common in preschoolers as well, and follow a similar epidemiologic profile
as in older children. An epidemiologic survey using the Preschool Age Psychiatric
Assessment (PAPA) found that 9.5 percent of preschoolers met criteria for any anxiety
disorder, with 6.5 percent exhibiting generalized anxiety disorder, 2.4 percent meeting
criteria for separation anxiety disorder, and 2.2 percent meeting criteria for social
phobia. Separation anxiety disorder is estimated to be about 4 percent in children and
young adolescents. Separation anxiety disorder is more common in young children than
in adolescents and has been reported to occur equally in boys and girls. The onset may
occur during preschool years, but is most common in children 7 to 8 years of age. The
rate of generalized anxiety disorder in school-age children is estimated to be
approximately 3 percent, the rate of social phobia is 1 percent, and the rate of simple
phobias is 2.4 percent. In adolescents, lifetime prevalence for panic disorder was found
to be 0.6 percent; the prevalence for generalized anxiety disorder was 3.7 percent.
ETIOLOGY
Biopsychosocial Factors
Evidence for the influences of parental psychopathology and parenting styles on the
emergence of anxiety disorders in childhood has been found in multiple investigations.
Longitudinal studies have found that parental overprotection has been associated with
an increased risk of the development of anxiety disorders in children, and insecure
parent–child attachment is associated with higher than expected rates of anxiety
disorders in childhood. It is also well known that maternal depression and anxiety have
led to an increased risk for anxiety and depression in children. Psychosocial factors in
conjunction with a child’s temperament influences the degree of separation anxiety
evoked in situations of brief separation and exposure to unfamiliar environments. The
temperamental trait of shyness and withdrawal in unfamiliar situations has been shown
to be associated with a higher risk of developing separation anxiety disorder,

generalized anxiety disorder, social anxiety disorder, or all three during childhood and
adolescence.
External life stresses often coincide with development of the disorder. The death of a
relative, a child’s illness, a change in a child’s environment, or a move to a new
neighborhood or school is frequently noted in the histories of children with separation
anxiety disorder. In a vulnerable child, these changes probably intensify anxiety.
Neurophysiological correlations are found with behavioral inhibition (extreme
shyness); children with this constellation are shown to have a higher resting heart rate
and an acceleration of heart rate with tasks requiring cognitive concentration.
Additional physiological correlates of behavioral inhibition include elevated salivary
cortisol levels, elevated urinary catecholamine levels, and greater papillary dilation
during cognitive tasks.
Neuroimaging studies of adolescents with anxiety show an increased activation of the
amygdala compared to non-anxious adolescents when presented with anxiety-provoking
stimuli. Furthermore, anxious adolescents maintain the hyperactivation of the amygdala
over time, rather than showing an attenuation of the effect as in nonanxious
adolescents. Structural studies of the amygdala in adolescents with anxiety have led to
conflicting results, some studies finding increased amygdala volumes, whereas other
studies finding decreased amygdala volumes.
Social Learning Factors
Fear, in response to a variety of unfamiliar or unexpected situations, may be
unwittingly communicated from parents to children by direct modeling. If a parent is
fearful, the child will probably have a phobic adaptation to new situations, especially to
a school environment. There are much data to suggest that overprotective parenting
promotes increased interpersonal sensitivity in healthy children, and increases the risk
of social anxiety disorder in children with behavioral inhibition or other anxiety
disorders such as separation anxiety disorder. Some parents appear to teach their
children to be anxious by overprotecting them from expected dangers or by
exaggerating the dangers. For example, a parent who cringes in a room during a
lightning storm teaches a child to do the same. A parent who is afraid of mice or insects
conveys the affect of fright to a child. Conversely, a parent who becomes angry with a
child when the child expresses fear of a given situation, for example, when exposed to
animals, may promote a phobic concern in the child by exposing the child to the
intensity of the anger expressed by the parent. Social learning factors in the
development of anxiety reactions are magnified when parents have anxiety disorders
themselves. These factors may be pertinent in the development of separation anxiety
disorder as well as in generalized anxiety disorder and social phobia. A recent study
found no association between psychosocial hardships, such as ongoing family conflict,
and behavioral inhibition among young children. It appears that temperamental
predisposition to anxiety disorders emerges as a highly heritable constellation of traits,
and is not created by psychosocial stressor.

Genetic Factors
Genetic studies suggest that genes account for at least one third of the variance in the
development of anxiety disorders. Heritability for anxiety disorders in children and
adolescents ranges from 36 percent to 65 percent, with the highest estimates found in
younger children with anxiety disorders. Two heritable characteristics—behavioral
inhibition (the tendency toward fear and withdrawal in new situations) and
physiological hyperarousal—have both been found to impart significant risk factors for
future development of an anxiety disorder. However, although the temperamental
constellation of behavioral inhibition, excessive shyness, the tendency to withdraw from
unfamiliar situations, and the eventual emergence of anxiety disorders have a genetic
contribution, one third to two thirds of young children with behavioral inhibition do not
appear to go on to develop anxiety disorders.
Family studies have shown that the offspring of adults with anxiety disorders are at
an increased risk of having an anxiety disorder themselves. Separation anxiety disorder
and depression in children overlap, and the presence of an anxiety disorder increases
the risk of a future episode of a depressive disorder. Current consensus on the genetics
of anxiety disorders suggests that what is inherited is a general predisposition toward
anxiety, causing heightened levels of arousal, emotional reactivity, and increased
negative affect, all of which increase the risk of developing separation anxiety disorder,
generalized anxiety disorder, and social phobia.
DIAGNOSIS AND CLINICAL FEATURES
Separation anxiety disorder, generalized anxiety disorder, and social phobia are highly
related in children and adolescence because, in most children, overlapping symptoms as
well as comorbid disorders emerge. Generalized anxiety disorder is the most common
anxiety disorder among youth, more common in adolescents than in younger children;
in almost one third of these cases, a child with generalized anxiety disorder also exhibits
separation anxiety disorder and social anxiety disorder.
Diagnostic criteria for separation anxiety disorder, according to the DSM-5, include
three of the following symptoms for at least 4 weeks: persistent and excessive worry
about losing, or possible harm befalling, major attachment figures; persistent and
excessive worry that an untoward event can lead to separation from a major attachment
figure; persistent reluctance or refusal to go to school or elsewhere because of fear of
separation; persistent and excessive fear or reluctance to be alone or without major
attachment figures at home or without significant adults in other settings; persistent
reluctance or refusal to go to sleep without being near a major attachment figure or to
sleep away from home; repeated nightmares involving the theme of separation;
repeated complaints of physical symptoms, including headaches and stomachaches,
when separation from major attachment figures is anticipated; and recurrent excessive
distress when separation from home or major attachment figures is anticipated or
involved. The following case history demonstrates separation anxiety disorder along

with autonomic arousal symptoms.
Jake was a 9-year-old boy who was referred for outpatient evaluation by his family
physician. He refused to sleep in his room alone at night and exhibited violent
tantrums each morning in order to avoid going to school. Jake expressed recurrent
fears that something bad would happen to his mother. He worried that she would get
into a car accident or that there would be a fire at home and his mother would be
killed. Developmental history revealed that Jake was anxious and irritable as an
infant and toddler. He had trouble adjusting to babysitters in the preschool years.
There was a history of panic disorder, with agoraphobia in the mother and major
depression in his father. Jake became more concerned and territorial over his mother
when his father left the family, and his mother became depressed. Jake always kept
track of his mother’s whereabouts and insisted that she stay at home.
Nighttime was a particularly difficult time at home. When Jake’s mother tried to get
Jake to remain in his room, Jake would whine and cry and insist that his mother lie in
bed with him until he fell asleep. He also expected his mother to be in the master
bedroom across the hall from his room throughout the evening. Jake’s mother
reported that that each evening her son would get up and peek through the crack in
the master bedroom door, as frequently as every 10 minutes, to be certain that she
was still there. Jake reported frequent nightmares that his mother was killed and that
monsters prevented him from rescuing his mother, taking him away from his family
forever.
During the daytime, Jake would shadow his mother around the house. Jake would
agree to play a game with his sister in the lower level of the house only if his mother
was close by. When Jake’s mother went upstairs, he would interrupt the game and
follow her upstairs. He refused to sleep at a friend’s house. Frequently, at home as the
evening progressed, Jake described a queasy sensation in his stomach mixed with
feelings of sadness.
On school days, Jake usually complained of stomachaches and tried to stay home.
Jake appeared distressed and panicky and would become violent when his mother
attempted to drop him off at school. Once at school, he seemed calmer and less
distressed, but frequently was seen in the nurse’s office, complaining of nausea and
seeking to be sent home. (Adapted from case material from Gail A. Bernstein, M.D.
and Anne E. Layne, Ph.D.)
The essential feature of separation anxiety disorder is extreme anxiety precipitated by
separation from parents, home, or other familiar surroundings, whereas in generalized
anxiety disorder, fears are extended to negative outcomes for all kinds of events,
including academic, peer relationship, and family activities. In generalized anxiety
disorder, a child or adolescent experiences at least one recurrent physiological symptom,
such as restlessness, poor concentration, irritability, or muscle tension. In social phobia,
the child’s fears peak during performance situations involving exposure to unfamiliar

people or situations. Children and adolescents with social phobia have extreme concerns
about being embarrassed, humiliated, or negatively judged. In each of the preceding
anxiety disorders, the child’s experience can approach terror or panic. The distress is
greater than that normally expected for the child’s developmental level and cannot be
explained by any other disorder. Morbid fears, preoccupations, and ruminations
characterize separation anxiety disorder. Children with anxiety disorders overestimate
the probability of danger and the likelihood of negative outcome. Children with
separation anxiety disorder and generalized anxiety disorder become overly fearful that
someone close to them will be hurt or that something terrible will happen to them or
their families, especially when they are away from important caring figures. Many
children with anxiety disorders are preoccupied with health and worry that their
families or friends will become ill. Fears of getting lost, being kidnapped, and losing the
ability to be in contact with their families is predominant among children with
separation anxiety disorder.
Adolescents with anxiety disorders may not directly express their worries; however,
their behavior patterns often reflect either separation anxiety or other anxiety if they
exhibit discomfort about leaving home, engage in solitary activities because of fears
about how they will perform in front of peers, or have distress when away from their
families. Separation anxiety disorder in children is often manifested at the thought of
travel or in the course of travel away from home. Children may refuse to go to camp, a
new school, or even a friend’s house. Frequently, a continuum exists between mild
anticipatory anxiety before separation from an important figure and pervasive anxiety
after the separation has occurred. Premonitory signs include irritability, difficulty
eating, whining, staying in a room alone, clinging to parents, and following a parent
everywhere. Often, when a family moves, a child displays separation anxiety by intense
clinging to the mother figure. Sometimes, geographical relocation anxiety is expressed
in feelings of acute homesickness or psychophysiological symptoms that break out when
the child is away from home or is going to a new country. The child yearns to return
home and becomes preoccupied with fantasies of how much better the old home was.
Integration into the new life situation may become extremely difficult. Children with
anxiety disorders may retreat from social or group activities and express feelings of
loneliness because of their self-imposed isolation.
Sleep difficulties are frequent in children and adolescents with any anxiety disorder or
in severe separation anxiety; a child or adolescent may require having someone remain
with him or her until he or she falls asleep. An anxious child may awaken and go to a
parent’s bed or even sleep at the parents’ door in an effort to diminish anxiety.
Nightmares and morbid fears may be expressions of anxiety (Fig. 31.13a-1).

FIGURE 31.13a-1
This surrealistic photograph symbolically represents the anxiety in a childhood
nightmare. (Courtesy of Arthur Tress for Magnum Photos, Inc.)
Associated features of most anxiety disorders include fear of the dark and imaginary
worries. Children may have the feeling that eyes are staring at them and monsters are
reaching out for them in their bedrooms. Children with separation anxiety disorder,
generalized anxiety disorder, and social anxiety disorder often complain of somatic
symptoms and may be more sensitive to changes in their bodies compared to youth
without anxiety disorders. Children with separation anxiety disorder, generalized
anxiety disorder, or social anxiety disorder are often more emotionally sensitive than
peers and more easily brought to tears. Frequent somatic complaints accompanying
anxiety 
disorders 
include 
gastrointestinal 
symptoms, 
nausea, 
vomiting, 
and
stomachaches; unexplained pain in various parts of the body; sore throats; and flu-like
symptoms. Older children and adolescents typically complain of somatic experiences
classically reported by adults with anxiety, such as cardiovascular and respiratory
symptoms—palpitations, 
dizziness, 
faintness, 
and 
feelings 
of 
strangulation.
Physiological signs of anxiety are a part of the diagnostic criteria for generalized
anxiety disorder, but they are more often also experienced by children with separation
anxiety and social phobia than the general population. The following case history
demonstrates a young adolescent with generalized anxiety disorder.

Rachel was a 13-year-old girl referred for an evaluation by her pediatrician based
on her chronic gastrointestinal complaints without any organic illness. On interview,
Rachel appeared withdrawn and meek but responsive to questions. She endorsed a
number of worries that included concerns about her health, her parents’ safety, her
school performance, and her peer relationships. Rachel’s greatest worries were related
to her health and safety. Rachel’s mother reported that Julie had recently been very
reluctant to play outside, because she feared she would contract Lyme disease from a
tick bite or West Nile virus from a mosquito bite. Rachel was also very distressed by
news reports about catastrophic events locally and around the world (e.g.,
kidnapping, crime, terrorism). Rachel was described by her family and teachers as
overly conscientious about her schoolwork and as often being concerned about adult
matters (e.g., finances, parents’ job security). Symptoms that accompanied Rachel’s
worries primarily involved stomach pain and problems falling asleep. Rachel tended
to be quite perseverative; repetitively verbalizing her worries even after reassurance
was given. Rachel admitted that she worried for hours each day and could not “turn
off” her worried thoughts.
Rachel was the product of a normal pregnancy and delivery. Her medical history
was unremarkable, with the exception of frequent gastrointestinal pain since
kindergarten. Julie was described as irritable and difficult to soothe as an infant.
Developmental milestones were met within normal limits. She was described as very
obedient and had no history of externalizing behavior problems. She was very
concerned about her academic performance from an early age and earned A’s with an
occasional B. Rachel was somewhat shy in social situations but well-liked by her
peers. Family history included depression in her maternal grandmother and a
maternal history of generalized anxiety disorder, social anxiety, and separation
anxiety disorder as a child. Rachel had two younger siblings who were high achievers
and without notable problems. (Adapted from case material from Gail A. Bernstein,
M.D., and Ann E. Layne, Ph.D.)
The next case history demonstrates an adolescent with multiple anxiety and
depressive disorders.
Kate is a 15-year-old 10th grader who lives with her biological parents and two
sisters, age 9 and 14 years. Kate is a very articulate teen who has always been a good
student, although she never volunteers answers in school unless she is called on by her
teachers. She gets along well with her sisters when at home, but ever since she entered
high school in the 9th grade year, she declines invitations to go to friends’ homes, has
turned down opportunities to go to parties, and has even stopped going on outings
with her sisters to the neighborhood mall and the movies. Kate reports that she gets
too nervous, and blushes when she is with friends outside of the classroom at school
because she can’t think of anything to say to them. She reports that she is embarrassed

to go shopping or to the movies with her sisters because they often run into
neighborhood peers along the way, stop to chat, and this makes her feel “stupid,”
because even though she is the oldest, she does not say anything, and believes that her
sisters’ friends will laugh at her shyness. Recently, one of her former best friends
confronted her about why she had stopped “hanging out” with her friends. Kate had
stopped eating lunch with her friends in school because she felt humiliated when they
would talk about their weekend plans and even when they invited her to join, she
would just look the other way and ignore the conversation. Kate had become isolated,
even in school, and admitted to her sister that she was lonely. Kate was brought for
an evaluation after her younger sister commented to her mother that Kate spent all of
her time alone whenever her sisters saw their friends, and that she looked sad and
stressed out whenever she was around peers. Kate was down, always in poor spirits
and had stopped interacting with her sisters even at home, and her sisters were often
out with their own friends. On rare occasions Kate’s younger sister had invited Kate to
parties or to friend’s homes, but Kate had declined and burst into tears.
Kate was evaluated by a child psychiatrist who made the diagnoses of social anxiety
disorder, generalized anxiety disorder, and major depression and recommended a
combination of treatment options, including cognitive-behavioral therapy (CBT) and
a trial of a selective serotonin reuptake inhibitor (SSRI), fluoxetine. Kate and her
family decided to try the medication first. Kate was started on 10 mg of fluoxetine and
over the next month was titrated to a dose of 20 mg. By the third week of the
medication trial, Kate was noticeably less resistant to going out with her sisters to
places where they were likely to encounter peers. Her sisters noticed that she did not
seem as stressed and started to occasionally sit with peers at lunch in the school
cafeteria. She stated that she did not feel as self-conscious as she used to in class and
was willing to go to a friend’s house. She still declined to go to a birthday party of a
peer that she didn’t know very well. Kate continued on the same medication and
within 2 months, she was significantly less anxious in social situations. She
complained occasionally of a stomachache, but tolerated the medication well. Her
family was impressed when she requested they plan a birthday party for her 16th
birthday and decided to invite 10 friends.
Pathology and Laboratory Examination
No specific laboratory measures help in the diagnosis of separation anxiety disorder,
generalized anxiety disorder, or social anxiety disorder.
DIFFERENTIAL DIAGNOSIS
The presence of separation anxiety is a developmentally expected feature in a young
child and often does not represent an impairing condition, thus clinical judgment must
be used in distinguishing normal anxiety from separation anxiety disorder in this age
group. In older school-age children, a child experiencing more than normal distress is

apparent when school is refused on a regular basis. For children who resist school, it is
important to distinguish whether fear of separation, general worry about performance,
or more specific fears of humiliation in front of peers or the teacher are driving the
resistance. In many cases in which anxiety is the primary symptom, all three of the
above-feared scenarios come into play. In generalized anxiety disorder, anxiety is not
primarily focused on separation.
When depressive disorders occur in children, possible comorbidities such as separation
anxiety disorder should be evaluated as well. A comorbid diagnosis of separation
anxiety disorder and depressive disorder should be made when the criteria for both
disorders are met; the two diagnoses often coexist. Panic disorder with agoraphobia is
uncommon before 18 years of age; the fear is of being incapacitated by a panic attack
rather than of separation from parental figures. School refusal is a frequent symptom in
separation anxiety disorder, but is not pathognomonic of it. Children with other
diagnoses, such as specific phobias, or social anxiety disorder, or fear of failure in school
because of learning disorder, may also lead to school refusal. When school refusal occurs
in an adolescent, the severity of the dysfunction is generally greater than when it
emerges in a young child. Similar and distinguishing characteristics of childhood
separation anxiety disorder, generalized anxiety disorder, and social anxiety disorder
are presented in Table 31.13a-1.
Table 31.13a-1
Common Characteristics in Childhood Anxiety Disorders
COURSE AND PROGNOSIS
The course and the prognosis of separation anxiety disorder, generalized anxiety
disorder, and social anxiety disorder are varied and are related to the age of onset, the
duration of the symptoms, and the development of comorbid anxiety and depressive

disorders. Young children who can maintain attendance in school, after-school activities,
and peer relationships generally have a better prognosis than children or adolescents
who refuse to attend school and withdraw from social activities. The large multisite
randomized clinical trial Child/Adolescent Anxiety Multimodal Study (CAMS) provided
acute treatment for children and adolescents with one or more anxiety disorders with
sertraline medication alone, cognitive-behavior therapy (CBT) alone, or both together,
and found that predictors of future remission included younger age of initiation of
treatment, lower severity of anxiety, absence of a comorbid depressive or anxiety
disorder, and the absence of social anxiety disorder as the primary anxiety disorder
being treated. A follow-up study of children and adolescents with mixed anxiety
disorders over a 3-year period reported that up to 82 percent no longer met criteria for
the anxiety disorder at follow-up. Of the group followed, 96 percent of those with
separation anxiety disorder were remitted at follow-up. Most children who recovered did
so within the first year. Early age of onset and later age at diagnosis were factors in this
study that predicted slower recovery. Close to one third of the group studied, however,
had developed another psychiatric disorder within the follow-up period, and 50 percent
of these children developed another anxiety disorder. Studies have shown a significant
overlap between separation anxiety disorder and depressive disorders. In cases with
multiple comorbidities, the prognosis is more guarded. Longitudinal data indicate that
some children with severe school refusal continue to resist attending school into
adolescence and remain impaired for many years.
TREATMENT
The treatment of child and adolescent separation anxiety disorder, generalized anxiety
disorder, and social anxiety disorder are often considered together, given the frequent
comorbidity and overlapping symptomatology of these disorders. A multimodal
comprehensive treatment approach usually includes psychotherapy, most often CBT,
family education, family psychosocial intervention, and pharmacological interventions,
such as SSRIs. The best evidence-based treatments for childhood anxiety disorders
include CBT and SSRIs. The comparative efficacy of CBT, SSRI medication, and their
combination (CBT + SSRI) in the treatment of childhood anxiety disorders was
investigated in the National Institute of Mental Health (NIMH)–funded Child/Adolescent
Anxiety Multimodal Study (CAMS). This double-blind, placebo-controlled, multi-site
study included 488 children and adolescents with separation anxiety disorder,
generalized anxiety disorder, or social anxiety disorder, who were randomly assigned to
be treated with either CBT alone, SSRI medication (sertraline) alone, both CBT and
sertraline, or placebo. After an acute treatment phase of 12 weeks, those in the
combined CBT + sertraline group had an 80.7 percent response rate of much or very
much improved on the clinical global improvement (CGI) rating. Response rates for the
CBT–only and sertraline-only groups were 59.7 percent and 54.9 percent, respectively.
Placebo response was 23.7 percent. Over time, during open follow-up, the combination
of CBT plus sertraline continued to provide the most efficacy. All three treatments—

CBT, sertraline, and their combination—were superior to placebo, and thus effective
treatments in childhood anxiety, but combined treatment was most likely to help
children and adolescents with anxiety disorders. A trial of CBT may be applied first, if
available, when a child is able to function sufficiently to engage in daily activities while
obtaining this treatment. For a child with severe impairment, however, a combination
of treatments is recommended. BT is widely accepted as first-line evidence-based
treatment for childhood anxiety disorders. A meta-analysis reviewed 16 randomized
controlled trials of CBT for childhood anxiety disorders and found CBT to be consistently
superior to a wait-list control group or a psychological placebo group. Exposure-based
CBT has received the most empiric support among psychotherapeutic interventions for
anxiety disorders in youth and has been shown to be superior to wait-list control groups
in reducing impairment and symptoms of anxiety.
Several psychosocial interventions have been designed specifically for anxiety
disorders in young children. A randomized clinical trial of CBT for 4- to 7-year-old
children was administered via a manualized intervention called “Being Brave: A
Program for Coping with Anxiety for Young Children and their Parents.” This manual
was loosely modeled after the manualized Coping Cat program. The intervention
utilized a combination of parent-only sessions and child-and-parent sessions. Response
rate, measured as much or very much improved on the Clinical Global Improvement
Scale for Anxiety, was 69 percent among completers versus 32 percent of the wait-list
controls. The treated children showed significantly better CGI improvement on social
anxiety disorder, separation anxiety disorder, and specific phobia, but not on
generalized anxiety disorder. This treatment, a developmentally modified parent–child
CBT, shows promise in young children.
Coaching Approach behavior and Leading by Modeling (the CALM program) is an
intervention aimed at treating anxiety disorders in children younger than 7 years of
age, who are too young to effectively engage in traditional CBT. The CALM program
draws on previous work with children aged 2 to 7 years through interventions that
target a child’s undesired behavior by modifying parents’ behavior, called Parent-Child
Interaction Therapy (PCIT). The CALM program is a 12-session manual-based
intervention that provides live, individualized coaching via a bug-in-the-ear receiver
worn by the parent during sessions. It incorporates exposure tasks and promotes
“brave” behavior with parent coaching. A pilot study using the CALM program with
nine patients with a mean age of 5.4 years found that all treatment completers (seven
patients and families) were rated as global responders, and all but one showed
functional improvement. Adapting the PCIT model for anxiety disorders in young
children appears to be a promising approach to treating anxiety in early childhood.
A meta-analysis of randomized controlled trials of antidepressant agents for childhood
anxiety provides evidence that multiple SSRIs, including fluvoxamine (Luvox),
fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) are efficacious in the
treatment of childhood anxiety. Based on this evidence, SSRIs are the first choice of
medication in the treatment of anxiety disorders in children and adolescents.
A large, multisite investigation by the National Institute of Mental Health (Research

Units in Pediatric Psychopharmacology [RUPP]) confirmed the safety and efficacy of
fluvoxamine in the treatment of childhood separation anxiety disorder, generalized
anxiety disorder, and social phobia. This double-blind, placebo controlled study of 128
children and adolescents revealed that 76 percent of children in the group treated with
fluvoxamine showed significant improvement compared with 29 percent of those in the
placebo group. Response to medication was noticeable after only two weeks of
treatment. Fluvoxamine dosages ranged from 50 mg to 250 mg per day in children and
up to 300 mg per day in adolescents. Children and adolescents with less comorbid
depressive symptoms had the best response. Children and adolescents who responded to
this medication were continued on fluvoxamine for a period of 6 months, and almost all
of them continued to be responders at the 6-month mark.
Several other randomized clinical trials have also supported the efficacy of SSRIs in
the treatment of child and adolescent anxiety disorders. A randomized, controlled trial
found fluoxetine, at a dose of 20 mg per day, to be safe and effective for children with
these disorders, with minor side effects including gastrointestinal distress, headache, and
drowsiness. In addition, a randomized clinical trial for the treatment of generalized
anxiety disorder in children lends support for the efficacy of sertraline (Zoloft). Finally,
a large industry randomized clinical trial of paroxetine (Paxil) in the treatment of
children with social phobia found that paroxetine was associated with response in 78
percent of children treated. Paroxetine was utilized at a dosage range of 10 to 50 mg
per day.
The Food and Drug Administration (FDA) has placed a “black box” warning on
antidepressants, including all of the SSRI agents, used in the treatment of any childhood
disorder, because of concerns about increased suicidality; however, no individual
childhood anxiety study has found a statistically significant increase in suicidal thoughts
or behaviors.
Tricyclic drugs are not currently recommended due to their potentially serious cardiac
adverse effects. β-Adrenergic receptor antagonists, such as propranolol (Inderal), and
buspirone (BuSpar) have been used clinically in children with anxiety disorders, but
currently no data support their efficacy. Diphenhydramine (Benadryl) may be used in
the short term to control sleep disturbances in children with anxiety disorders. Open
trials and one double-blind, placebo-controlled study suggested that alprazolam
(Xanax), a benzodiazepine, may help to control anxiety symptoms in separation anxiety
disorder. Clonazepam (Klonopin) has been studied in open trials and may be useful in
controlling symptoms of panic and other anxiety symptoms.
Although SSRIs and CBT alone and in combination have demonstrated efficacy in the
treatment of anxiety disorders in youth, approximately 20 to 35 percent of children and
adolescents with anxiety disorders do not appear to benefit. Several novel agents have
been suggested as potential treatments, some based on their effect on the N-methyl-daspartate (NMDA) system. For example, d-cycloserine (DCS), currently FDA approved in
the treatment of pediatric tuberculosis, is a partial receptor agonist of the NMDA system
and is hypothesized to augment the benefits of exposure treatment for phobias. Some

evidence suggests that DCS may increase the speed of exposure interventions; however,
long-term gains have not been proven. Riluzole is an antiglutamatergic agent that
decreases glutamatergic transmission by inhibiting glutamate release and inactivation of
sodium channels in cortical neurons, and blocking γ-aminobutyric acid (GABA)
reuptake. Due to its antiglutamatergic effects, Riluzole has been postulated to provide
augmentation in the treatment of obsessive-compulsive disorder and generalized anxiety
disorder. Another agent, memantine, an NMDA receptor antagonist, with FDA approval
in the treatment of Alzheimer’s disease, has been hypothesized to decrease anxiety due
to its influence on the glutamatergic system. Published case reports have provided mixed
results.
Although most childhood anxiety disorders wax and wane over time, school refusal
associated with separation anxiety disorder can be viewed as a psychiatric emergency. A
comprehensive treatment plan involves the child, the parents, and the child’s peers and
school. Family interventions are critical in the management of separation anxiety
disorder, especially in children who refuse to attend school, so that firm encouragement
of school attendance is maintained while appropriate support is also provided. When a
return to a full school day is overwhelming, a program should be arranged so the child
can progressively increase the time spent at school. Graded contact with an object of
anxiety is a form of behavior modification that can be applied to any type of separation
anxiety. Some severe cases of school refusal require hospitalization. Cognitivebehavioral modalities include exposure to feared separations and cognitive strategies,
such as coping self-statements aimed at increasing a sense of autonomy and mastery.
In summary, evidence-based treatments for anxiety disorders have focused SSRIs and
CBT. SSRIs have been shown to be both safe and efficacious in the treatment of
childhood anxiety disorders; however, in severe disorders, the evidence suggests that
optimal treatment is to provide both CBT and SSRI antidepressant agents
simultaneously.
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