order, psychological treatment of that disorder may
improve the elimination disorder (Mikkelsen, 2000).
◗ OTHERDISORDERS OFINFANCY,
CHILDHOOD, ORADOLESCENCE
SEPARATION ANXIETY DISORDER
Separation anxiety disorder is characterized by anx-
iety exceeding that expected for developmental level
related to separation from the home or those to whom
the child is attached (APA, 2000). When apart from
attachment figures, the child insists on knowing their
whereabouts and may need frequent contact with
them such as phone calls. These children are mis-
erable away from home and may fear never seeing
their homes or loved ones again. They often follow
parents like a shadow, will not be in a room alone,
and have trouble going to bed at night unless some-
one stays with them. Fear of separation may lead to
avoidance behaviors such as refusal to attend school
or go on errands. Separation anxiety disorder often is
accompanied by nightmares and multiple physical
complaints such as headaches, nausea, vomiting, and
dizziness.
Separation anxiety disorders are thought to re-
sult from an interaction between temperament and
parenting behaviors. Inherited temperament traits,
such as passivity, avoidance, fearfulness, or shyness
in novel situations, coupled with parenting behaviors
that encourage avoidance as a way to deal with
strange or unknown situations are thought to cause
anxiety in the child (Sylvester, 2000).
Depending on the severity of the disorder, chil-
dren may have academic difficulties and social with-
drawal if their avoidance behavior keeps them from
school or relationships with others. Children may be
described as demanding, intrusive, and in need of
constant attention, or they may be compliant and
eager to please. As adults, they may be slow to leave
the family home or overly concerned about and pro-
tective of their own spouses and children. They may
continue to have marked discomfort when separated
from home or family. Parent education and family
therapy are essential components of treatment; 80%
of children experience remission at 4-year follow-up
(Sylvester, 2000).
SELECTIVE MUTISM
Selective mutism is characterized by persistent fail-
ure to speak in social situations where speaking is
expected, such as school (APA, 2000). Children may
communicate by gestures, nodding or shaking the
head, or occasionally one-syllable vocalizations in a
voice different from their natural voice. These chil-
dren are often excessively shy, socially withdrawn
or isolated, and clinging; they may have temper
tantrums. Selective mutism is rare and slightly more
common in girls than in boys. It usually lasts only a
few months but may persist for years.REACTIVE ATTACHMENT DISORDER
Reactive attachment disorder involves a markedly
disturbed and developmentally inappropriate social
relatedness in most situations. This disorder usually
begins before 5 years of age and is associated with
grossly pathogenic care such as parental neglect,
abuse, or failure to meet the child’s basic physical or
emotional needs. Repeated changes in primary care-
givers, such as multiple foster care placements, also
can prevent the formation of stable attachments
(APA, 2000). The disturbed social relatedness may be
evidenced by the child’s failure to initiate or respond
to social interaction (inhibited type) or indiscrimi-
nate sociability or lack of selectivity in choice of at-
tachment figures (disinhibited type). In the first type,
the child will not cuddle or desire to be close to any-
one. In the second type, the child’s response is the
same to a stranger or to a parent.
Initially, treatment focuses on the child’s safety,
including removal of the child from the home if ne-
glect or abuse is found. Individual and family ther-
apy (either with parents or foster caregivers) is most
effective. With early identification and effective in-
tervention, remission or considerable improvements
can be attained. Otherwise the disorder follows a
continuous course with relationship problems per-
sisting into adulthood.STEREOTYPIC MOVEMENT
DISORDER
Stereotypic movement disorder is associated with
many genetic, metabolic, and neurologic disorders
and often accompanies mental retardation. The pre-
cise cause is unknown. It involves repetitive motor
behavior that is nonfunctional and either interferes
with normal activities or results in self-injury re-
quiring medical treatment (APA, 2000). Stereotypic
movementsmay include waving, rocking, twirling
objects, biting fingernails, banging the head, biting
or hitting oneself, or picking at the skin or body ori-
fices. Generally speaking, the more severe the retar-
dation, the higher the risk for self-injury behaviors.
Stereotypic movement behaviors are relatively stable
over time but may diminish with age (Luby, 2000).
No specific treatment has been shown effective.
Clomipramine (Anafranil) and desipramine (Nor-
pramin) are effective in treating severe nail-biting;20 CHILD ANDADOLESCENTDISORDERS 505