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takes only a few hours of skilled treatment to bring about a complete and
lasting cure.
Separation anxiety disorder
Anxiety about separation from parents and other major attachment figures
usually emerges at around six months and remains prominent during the
preschool years, subsequently waning as the child acquires the ability
to keep attachment figures, and the security they provide, ‘in mind’
even when they are not physically present. Separation anxiety disorder
is diagnosed when the intensity of separation anxiety is developmentally
inappropriate and leads to substantial social incapacity, for example, re-
fusal to go to school. ICD-10 criteria stipulate early onset (before the age
of 6) whereas DSM-IV criteria are less restrictive, allowing the diagnosis to
be made provided the onset occurs before the age of 18.
Causation
Constitutional factors and family environment may both be important.
Styles of parental interaction that may contribute include: modelling
avoidant or anxious behaviour through over-protectiveness; evoking anx-
iety through harsh child-rearing practices that may include threats of
abandonment; and failure to soothe children effectively when they do
become anxious.
Characteristic features
Affected children (and more rarely adolescents) worry unrealistically that
their parents will come to harm or leave and not return. They also worry
about themselves, fearing that they will get lost, be kidnapped, be admitted
to hospital, or be separated from their parents as the result of some
other calamity. These worries may also emerge as themes of recurrent
nightmares. Affected individuals are commonly clingy even in their own
home, for example, following a parent from room to room. There may be
reluctance or refusal to attend school, or to sleep alone, or to sleep away
from home. Separations, or the anticipation of separations, may result in
pleading, tantrums and tears, or may result in purely physical complaints,
for example, headaches, stomach-aches, nausea.
Epidemiology
Separation anxiety disorder affects about 1–2% of children and adoles-
cents, being commoner in prepubertal children than adolescents, and
affecting roughly equal numbers of males and females.
Treatment
Operant techniques (for example, star charts or contingency management)
may be used to alter the balance of rewards and disincentives that favour
clinging rather than separation. Graded exposure to increasingly more
demanding separations can be useful. Cognitive therapy may have a place,
teaching the child or adolescent to use coping self-statements. If separation