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Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

  1. Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following:

    1. recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated

    1. persistent and excessive worry about losing, or about possible harm befalling, major attachment figures

    1. persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped)

    1. persistent reluctance or refusal to go to school or elsewhere because of fear of separation

    1. persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings

    1. persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home

    1. repeated nightmares involving the theme of separation

    1. repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated

  2. The duration of the disturbance is at least 4 weeks.

  3. The onset is before age 18 years.

  4. The disturbance causes clinically significant distress or impairment in social, academic (occupation), or other important areas of functioning.

  5. The disturbance does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and, in adolescents and adults, is not better accounted for by panic disorder with agoraphobia.

Specify if:

Early onset: if onset occurs before age 6 years.

(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Copyright 2000, Washington, DC: American Psychiatric Association.)

General Considerations


Separation anxiety disorder (SAD) occurs in 2–4% of children and adolescents. It represents about 50% of all referrals for evaluation of anxiety disorder at this age. SAD may be slightly more prevalent in girls and in families of lower socioeconomic status. School refusal is equally common in all socioeconomic groups. Its incidence is 1–2% in school-aged children, and it may be more common in boys.


SAD is linked to insecure attachment (see Chapter 45). It may be precipitated by loss, separation, or the threat of either. Parental anxiety and an enmeshed mother–child relationship is commonly associated with this condition. The combination of parental anxiety and depression is an additional risk factor. The prevalence of anxiety disorders in other family members might indicate a genetic factor.

A psychodynamic theory concerning the etiology of SAD postulates the following: (1) The mother has a hostile-dependent relationship with her own mother, (2) the mother is lonely and unsatisfied in her marriage, (3) following a threat to security, the child responds to an overly dependent relationship with the mother, (4) the ...

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