Separation anxiety disorder

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"Separation anxiety" redirects here. For other uses, see Separation anxiety (disambiguation).
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Separation anxiety disorder
Classification and external resources
ICD-10 F93.0
ICD-9 309.21
DiseasesDB 34361
eMedicine article/916737
MeSH D001010

Separation anxiety disorder (SAD) is a psychological condition in which an individual experiences excessive anxiety regarding separation from home or from people to whom the individual has a strong emotional attachment (e.g. a parent, caregiver, or siblings). In infants and small children, typically between the ages of 2 months to 3 years, separation anxiety is a natural part of the developmental process. Unlike SAD, this process indicates healthy advancements in a child’s cognitive maturation and should not be considered a developing behavioral problem.[1]

According to the American Psychology Association, separation anxiety disorder is the inappropriate and excessive display of fear and distress when faced with situations of separation from the home or from a specific attachment figure. The anxiety that is expressed is categorized as being atypical of the expected developmental level and age.[2] The severity of the symptoms ranges from anticipatory uneasiness to full-blown anxiety about separation.[3]

SAD may cause significant negative effects within areas of social and emotional functioning, family life, and physical health of the disordered individual.[2] The duration of this problem must persist for at least four weeks and must present itself before a child is 18 years of age to be diagnosed as SAD, as specified by the DSM-5.[4]

Prevalence[edit]

Anxiety disorders are the most common type of psychopathology to occur in today's youth, affecting from 5–25% of children world-wide.[2] Of these anxiety disorders, SAD accounts for a large proportion of diagnoses. SAD may account for up to 50% of the anxiety disorders as recorded in referrals for mental health treatment.[2] SAD is noted as one of the earliest-occurring of all anxiety disorders.[4] Adult separation anxiety disorder affects roughly 7% of adults. It has also been reported that the clinically anxious pediatric population are considerably larger. For example, according to Hammerness et. al (2008) SAD accounted for 49% of admissions.[5]

Research suggests that 4.1% of children will experience a clinical level of separation anxiety. Of that 4.1% it is calculated that nearly a third of all cases will persist into adulthood if left untreated.[2] Research continues to explore the implications that early dispositions of SAD in childhood may serve as risk factors for the development of mental disorders throughout adolescence and adulthood.[6] It is presumed that a much higher percentage of children suffer from a small amount of separation anxiety, and are not actually diagnosed. Multiple studies have found higher rates of SAD in girls than in boys, and that paternal absence may increase the chances of SAD in girls.[7]

Classification[edit]

Separation anxiety is common for infants between the ages of eight to fourteen months and occurs as infants begin to understand their own selfhood—or understand that they are a separate person from their primary caregiver. Infants often times look for their caregiver(s) to give them a sense of comfort and familiarity, which causes separation to become challenging.[8] Subsequently, the concept of object permanence emerges—which is when children learn that something still exists when it cannot be seen or heard, thus increasing their awareness of being separated from their caregiver. Consequently, with the emergence of an infants sense of self and object permanence is a developmental period when the child begins to understand that they can be separated from their primary caregiver, but, cannot yet understand that their caregiver will return causing fear and distress for the infant.

One of the difficulties in the identification of separation anxiety disorder in children is that it highly comorbid with other behavioral disorders, especially generalized anxiety disorder. Behaviors such as refusal or hesitancy in attending school or homesickness for example, can easily reflect similar symptoms and behavioral patterns that are commonly associated with SAD. but could be an overlap of symptoms. The prevalence of co-occuring disorders in adults with separation anxiety disorder is common and includes a much broader spectrum of diagnostic possibilities. Common comorbidities can include specific phobias, PTSD, panic disorder, obsessive-compulsive disorder, and personality disorders.[9] Because of the variation and overlap in symptoms proper, thorough evaluation of the individual is critical in distinguish the differences and significance.[10]

Criteria for diagnosis[edit]

Separation anxiety occurs in many infants and young children as they are becoming acclimated with their surroundings. This anxiety is viewed as a normal developmental phase between the months of early infancy until age two.[2] Other sources note that a definite diagnosis of SAD should not be presented until after the age of three.[11] Separation anxiety may be diagnosed as a disorder if the child's anxiety related to separation from the home or attachment figure is deemed excessive; if the level of anxiety surpasses that of the acceptable caliber for the child's developmental level and age; and if the anxiety negatively impacts the child's everyday life.[2]

Assessment methods and tools[edit]

Assessment methods include diagnostic interviews, self-report measures from both the parent and child, observation of parent-child interaction, and specialized assessment for preschool-aged children. Various facets of a child's development including social life, feeding and sleep schedules, medical issues, traumatic events experienced, family history of mental or anxiety health issues are explored. The compilation of aspects of a child's life aids in capturing a multi-dimensional view of the child's life.[11]

Additionally, while much research has been done in efforts to further understand separation anxiety in regards to the relationship between infants’ and their caregivers, it was behavioral psychologist, Mary Ainsworth, who devised a behavioral evaluation method, The Strange Situation (1969), which, at the time, was considered to be the most valuable and famous body of research in the study of separation anxiety. The Strange Situation process assisted in evaluating and measuring the individual attachment styles of infants between the ages of 9 and 18 months. In this observational study, which can be watched by clicking the link ("The Strange Situation Study") below, an environment is created that fluctuates between familiar and unfamiliar situations that would be experienced in everyday life. The variations in stressfulness and the child’s responses are observed and, based on the interaction behavior that is directed towards the caregiver, the infant is categorized into one of four different types of attachment styles: 1. Secure (B) 2. Anxious-avoidant, Insecure (A) 3. Anxious-ambivalent/resistant, insecure (C) 4. Disorganized/disoriented (D).[12]

Clinicians may utilize interviews as an assessment tool to gauge the symptomatic occurrences to aid in diagnosing SAD. Interviews may be conducted with the child and also with the attachment figure. Interviewing both child and parent separately allows for the clinician to compile different points of view and information.[2]

Commonly used interviews include:[2]

  • Anxiety Disorders Interview Schedule for the DSM-IV, Child Parent Versions (ADIS-IV-C/P)
  • Diagnostic Interview Schedule for Children, Version IV (DISC-IV)
  • Schedule for Affective Disorders and Schizophrenia for School-aged Children-Present and lifetime version IV (K-SADS-IV)

Self-report measures[edit]

This form of assessment should not be the sole basis of a SAD diagnosis. It is also important to verify that the child who is reporting on their experiences has the cognitive and communication skills appropriate to accurately comprehend and respond to these measurements.[2] An example of a self-report tool that has been tested is: The Separation Anxiety Assessment Scale for Children (SAAS-C). The scale contains 34 items and is divided into six dimensions. The dimensions in order are: Abandonment, Fear of Being Alone, Fear of Physical Illness, Worry about Calamitous Events, Frequency of Calamitous Events, and Safety Signal Index. The first five dimensions have a total of five items while the last one contains nine items. The scale goes beyond assessing symptoms; it focuses on individual cases and treatment planning.[13]

Observation[edit]

As noted by Altman, McGoey & Sommer, it is important to observe the child, "in multiple contexts, on numerous occasions, and in their everyday environments (home, daycare, preschool)".[11] It is beneficial to view parent and child interactions and behaviors that may contribute to SAD.[2]

Dyadic Parent-Child Interaction Coding System and recently the Dyadic Parent-Child Interaction Coding System II (DPICS II) are methods used when observing parents and children interactions.[14]

Separation Anxiety Daily Diaries (SADD) have also been used to “assess anxious behaviors along with their antecedents and consequences and may be particularly suited to SAD given its specific focus on parent–child separation” (Silverman & Ollendick, 2005). The diaries are carefully evaluated for validity.[15]

Assessment of preschool-aged children[edit]

At the preschool-aged stage, early identification and intervention is crucial.[2] The communication abilities of young children are taken into consideration when creating age-appropriate assessments.[11]

A commonly used assessment tool for preschool-aged children (ages 2–5) is the Preschool Age Psychiatric Assessment (PAPA).[2] Additional questionnaires and rating scales that are used to assess the younger population include the Achenbach Scales, the Fear Survey Schedule for Infants and Preschoolers, and The Infant–Preschool Scale for Inhibited Behaviors.[11]

Preschool children are also interviewed. Two interviews that are sometimes conducted are Attachment Doll-Play and Emotional Knowledge. In both of the assessments the interviewer depicts a scenario where separation and reunion occur; the child is then told to point at one of the four facial expressions presented. These facial expressions show emotions such as anger or sadness. The results are then analyzed.[16]

Behavioral observations are also utilized when assessing the younger population. Observations enable the clinician to view some of the behaviors and emotions in specific contexts.[11]

Contributing factors and etiology[edit]

Factors that contribute to the disorder include a combination and interaction of biological, cognitive, environmental, child temperament, and behavioral factors.

Environmental[edit]

Most often, the onset of separation anxiety disorder is caused by a stressful life-event, especially a loss of a loved one or pet, but can also include parental divorce, change of school or neighborhood, natural disasters, circumstances which forced the individual to be separated from their attachment figure(s). In older individuals, stressful life experiences may include going away to college, moving out for the first time, or becoming a parent.[17]

Genetic and physiological[edit]

There may be a genetic predisposition in children with separation anxiety disorder, "Separation anxiety disorder in children may be heritable.[18] "Heritability was estimated at 73% in a community sample of 6-year-old twins, with higher rates in girls" [19]

A child's temperament can also impact the development of SAD. Timid and shy behaviors may be referred to as "behaviorally inhibited temperaments" in which the child may experience anxiety when they are not familiar with a particular location or person.[11]

In the academic setting[edit]

As with other anxiety disorders, children with SAD face more obstacles at school than those without anxiety disorders. Adjustment and relating school functioning have been found to be much more difficult for anxious children.[20] In some severe forms of SAD, children may act disruptively in class or may refuse to attend school altogether. It is estimated that nearly 75% of children with SAD exhibit some form of school refusal behavior.[2]

This is a serious problem because, as children fall further behind in coursework, it becomes increasingly difficult for them to return to school.[21]

Short-term problems resulting from academic refusal include poor academic performance or decline in performance, alienation from peers, and conflict within the family.[2]

Although school refusal behavior is common among children with SAD, it is important to note that school refusal behavior is sometimes linked to generalized anxiety disorder or possibly a mood disorder.[22]

Neural correlates[edit]

Preliminary evidence shows that heightened activity of the amygdala may be associated with symptoms of separation anxiety disorder. Defects in the ventrolateral and dorsomedial areas of the prefrontal cortex are also correlated to anxiety disorders in children.[23]

Treatment[edit]

Non-pharmacological[edit]

Non-pharmacological treatments are the first choice when treating individuals diagnosed with separation anxiety disorder.[3] Counseling tends to be the best replacement for drug treatments. There are two different non-pharmacological approaches to treat separation anxiety. The first is a psychoeducational intervention, often used in conjunction with other therapeutic treatments.[3] This specifically involves educating the individual and their family so that they are knowledgeable about the disorder, as well as parent counseling and guiding teachers on how to help the child.[3] [24] The second is a psychotherapeutic intervention when prior attempts are not effective. Psychotherapeutic interventions are more structured and include behavioral, cognitive-behavioral, contingency, psychodynamic psychotherapy, and family therapy.[3]

Anchors Away program for children with anxiety disorder.

Behavioral therapy[edit]

Behavioral therapies are types of non-pharmacological treatment which are mainly exposure-based techniques. These include techniques such as systematic desensitization, emotive imagery, participant modelling and contingency management. Behavioral therapies carefully expose individuals by small increments to slowly reduce their anxiety over time and mainly focuses on their behavior.[25]

Contingency management[edit]

Contingency management is a form of treatment found to be effective for younger children with SAD. Contingency management revolves around a reward system with verbal or tangible reinforcement requiring parental involvement. A contingency contract is written up between the parent and the child, which entails a written agreement about specific goals that the child will try to achieve and the specific reward the parent will provide once the task is accomplished.[26] When the child undergoing contingency management show signs of independence or achieve their treatment goals, they are praised or given their reward.[27] This facilitates a new positive experience with what used to be filled with fear and anxiety. Children in preschool who show symptoms of SAD do not have the communicative ability to express their emotions or the self-control ability to cope with their separation anxiety on their own, so parental involvement is crucial in younger cases of SAD.[3]

Cognitive behavioral therapy (CBT)[edit]

Cognitive behavioral therapy focuses on helping children with SAD reduce feelings of anxiety through practices of exposure to anxiety-inducing situations and active metacognition to reduce anxious thoughts.[2]

CBT has 3 phases: education, application and relapse prevention.[26] In the education phase, the individual is informed on the different effects anxiety can have physically and more importantly mentally. By understanding and being able to recognize their reactions, it will help to manage and eventually reduce their overall response.[26]

According to Kendall and colleagues, there are four components which must be taught to a child undergoing CBT:[28]

  1. Recognizing anxious feelings and behaviors
  2. Discussing situations that provoke anxious behaviors
  3. Developing a coping plan with appropriate reactions to situations
  4. Evaluating effectiveness of the coping plan

In the application phase, individuals can take what they know and apply it in real time situations for helpful exposure. The most important aspect of this phase is for the individuals to ultimately manage themselves throughout the process.[26] In the relapse prevention phase, the individual is informed that continued exposure and application of what worked for them is the key to continual progress.[26]

A study investigated the content of thoughts in anxious children who suffered from separation anxiety as well as from social phobia and/or generalized anxiety. The results suggested that cognitive therapy for children suffering from separation anxiety (along with social phobia and generalized anxiety) should be aimed at identifying negative cognition of one's own behavior in the threat of anxiety-evoking situations and to modify these thoughts to promote self-esteem and ability to properly cope with the given situation.[29]

Cognitive procedures are a form of treatment found to be ideal for older children with SAD.[3] The theory behind this technique is that the child's dysfunctional thoughts, attitudes, and beliefs are what lead to anxiety and cause anxious behavior.[3] Children who are being treated with cognitive procedures are taught to ask themselves if there is "evidence" to support their anxious thoughts and behaviors.[3] They are taught "coping thoughts" to use during anxiety-inducing situations and to praise themselves for handling the situation bravely.[3] Sometimes therapists will involve parents and teach them behavioral tactics such as contingency management.[26]

Pharmacological[edit]

The use of pharmacological treatment, also known as pharmacotherapy, is applied in extreme cases of SAD when other treatment options have been utilized and failed.[3][28] However, it has been difficult to prove the benefits of drug treatment in patients with SAD because there have been many mixed results.[2] Despite all the studies and testings, there has yet to be a specific medication for SAD. Medication prescribed for adults from the Food and Drug Administration (FDA) are often used and have been reported to show positive results for children and adolescents with SAD.[30]

There are mixed results regarding the benefits of using tricyclic antidepressants (TCAs), which includes imipramine and clonipramine.[31] One study suggested that imipramine is helpful for children with “school phobia,” who also had an underlying diagnosis of SAD. However, other studies have also shown that imipramine and clonipramine had the same effect of children who were treated with the medication and placebo.[31] The most promising pharmacotherapy is the use of selective serotonin reuptake inhibitors (SSRI) in adults and children.[30] Several studies have shown that patients treated with fluvoxamine were significantly better than those treated with placebo.[2] They showed decreasing anxiety symptoms with short-term and long-term use of the medication.[2]

Prognosis[edit]

Discomfort from separations in children from ages 8 to 14 months is normal. Children often times get nervous or afraid of unfamiliar people and places but if the behavior still occurs after the age of 6 and if it lasts longer than four weeks, the child might have Separation Anxiety Disorder.[32] About 4% of children have the disorder. Separation Anxiety Disorder is very treatable especially when caught early on with pharmacological and behavioral therapies.[25] Helping children with separation anxiety to identify the circumstances that elicit their anxiety (upcoming separation events) is important. A child's ability to tolerate separations should gradually increase over time when he or she is gradually exposed to the feared events. Encouraging a child with separation anxiety disorder to feel competent and empowered, as well as to discuss feelings associated with anxiety-provoking events promotes recovery.

Children with separation anxiety disorder often respond negatively to perceived anxiety in their caretakers, in that parents and caregivers who also have anxiety disorders may unwittingly confirm a child's unrealistic fears that something terrible may happen if they are separated from each other. Thus, it is critical that parents and caretakers become aware of their own feelings and communicate a sense of safety and confidence about separation.[33]

Longitudinal effects[edit]

Several studies aim to understand the long-term mental health consequences of SAD.[6] SAD contributed to vulnerability and acted as a strong risk factor for developing mental disorders in people aged 19–30. Specifically disorders including panic disorder and depressive disorders were more likely to occur.[6] Other sources also support the increased likelihood of displaying either of the two psychopathologies with previous history of childhood SAD.[4]

See also[edit]

References[edit]

  1. ^ Davidson, Tish. "Separation Anxiety." Gale Encyclopedia of Children's Health: Infancy through Adolescence. 2006. Retrieved October 06, 2014 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3447200510.html
  2. ^ a b c d e f g h i j k l m n o p q r s Ehrenreich, J. T; Santucci, L. C.; Weinrer, C. L. (2008). "Separation anxiety disorder in youth: Phenomenology, assessment, and treatment". doi:10.1901/jaba.2008.16-389. PMC 2788956. 
  3. ^ a b c d e f g h i j k Masi, G.; Mucci, M.; Millepiedi, S. (2001). "Separation anxiety disorder in children and adolescents: epidemiology, diagnosis and management.". CNS Drugs 15 (2): 93–104. doi:10.2165/00023210-200115020-00002. PMID 11460893. 
  4. ^ a b c Beesdo, Katja; Knappe, Susanne; Pine, Daniel S. (September 2009). "Anxiety and Anxiety Disorders in Children and Adolescents: Developmental Issues and Implications for DSM-V". Psychiatric Clinics of North America 32 (3): 483–524. doi:10.1016/j.psc.2009.06.002. 
  5. ^ Hammerness P, Harpold T, Petty C, et al: Characterizing non-OCD anxiety disorders in psychiatrically referred children and adolescents. J Affect Disord 105(1-3):213-219, 2008
  6. ^ a b c Lewinsohn, P. M.; Holm-Denoma, J. M.; Small, J. W.; Seely, J. R (2008). "Separation anxiety disorder in childhood as a risk factor for future mental illness". Journal of the American Academy of Child and Adolescent Psychiatry 47 (5): 548–555. doi:10.1097/CHI.0b013e31816765e7. 
  7. ^ Cohen, P., Cohen, J., Kasen, S., Velez, C. N., Hartmark, C., Johnson, J., Rojas, M., Brook, J. and Streuning, E. L. (1993), An Epidemiological Study of Disorders in Late Childhood and Adolescence—I. Age- and Gender-Specific Prevalence. Journal of Child Psychology and Psychiatry, 34: 851–867. doi: 10.1111/j.1469-7610.1993.tb01094.x
  8. ^ Feigelman S. The first year. In: Kliegman RM, Stanton BF, St. Geme JW III, et al., eds. Nelson Textbook of Pediatrics, 19th ed. Philadelphia, PA: Elsevier Saunders; 2011:chap 8
  9. ^ American Psychiatric Association. (2013). Comorbidity of Separation Anxiety. In Diagnostic and statistical manual of mental disorders (5th ed.).doi:10.1176/appi.books.9780890425596.744053
  10. ^ Eisen, A., Sussman, J., Schmidt, T., Mason, L., Hausler, L., & Hasim, R. (2012). Separation Anxiety Disorder. In Handbook of Child and Adolescent Anxiety Disorders (2011 ed.). Springer
  11. ^ a b c d e f g Altman, C; McGoey, K. E.; Sommer, J. L (2009). "Anxiety in early childhood: what do we know?". Journal of early childhood and infant psychology. 
  12. ^ Mary Ainsworth | Attachment Styles | Simply Psychology. (n.d.). Retrieved November 27, 2014, from http://www.simplypsychology.org/mary-ainsworth.html
  13. ^ Chessa, D., di Riso, D., Delvecchio, E., & Lis, A. (2012). Assessing separation anxiety in Italian youth: Preliminary psychometric properties of the Separation Anxiety Assessment Scale. Perceptual And Motor Skills, 115(3), 811-832. doi:10.2466/03.10.15.PMS.115.6.811-832
  14. ^ Thornberry Jr., T., & Brestan-Knight, E. (2011). Analyzing the Utility of Dyadic Parent-Child Interaction Coding System (DPICS) Warm-Up Segments. Journal Of Psychopathology & Behavioral Assessment, 33(2), 187-195. doi:10.1007/s10862-011-9229-6
  15. ^ Allen, J. L., Blatter-Meunier, J., Ursprung, A., & Schneider, S. (2010). Maternal daily diary report in the assessment of childhood separation anxiety. Journal Of Clinical Child And Adolescent Psychology, 39(2), 252-259. doi:10.1080/15374410903532619
  16. ^ Bettmann, J., & Lundahl, B. (2007). Tell Me a Story: A Review of Narrative Assessments for Preschoolers. Child & Adolescent Social Work Journal, 24(5), 455-475. doi:10.1007/s10560-007-0095-8
  17. ^ Adults with separation anxiety may be invasive and overprotective of their friends and loved ones. American Psychiatric Association. (2013). Risk and Prognostic Factors of Separation Anxiety. In Diagnostic and statistical manual of mental disorders (5th ed.).doi:10.1176/appi.books.9780890425596.744053
  18. ^ American Psychiatric Association. (2013). Risk and Prognostic Factors of Separation Anxiety. In Diagnostic and statistical manual of mental disorders (5th ed.).doi:10.1176/appi.books.9780890425596.744053
  19. ^ Bolton D, Eley TC, O’Connor TG, et al: Prevalence and genetic and environmental influences on anxiety disorders in 6-year-old twins. Psychol Med 36(3):335–344, 2006
  20. ^ Mychailyszyn, Matthew P.; Mendez, Julia L.; Kendall, Philip C. (2010). "School Functioning in Youth with and without Anxiety Disorders: Comparisons by Diagnosis and Comorbidity". School Psychology Review 39 (1): 106–121. ISSN 0279-6015. 
  21. ^ Doobay, Alissa F. (April 2008). "School Refusal Behavior Associated with Separation Anxiety Disorder: A Cognitive-Behavioral Approach to Treatment". Psychology in the Schools 45 (4): 261–272. doi:10.1002/pits.20299. ISSN 0033-3085. 
  22. ^ Eisen, A., Sussman, J., Schmidt, T., Mason, L., Hausler, L., & Hasim, R. (2012). Separation Anxiety Disorder. In Handbook of Child and Adolescent Anxiety Disorders (2011 ed.). Springer.
  23. ^ Blackford, Jennifer U.; Daniel S. Pine (November 2012). "Neural Substrates of Childhood Anxiety Disorders A Review of Neuroimaging Findings". Child & Adolescent Psychiatric Clinics of North America 21 (3): 501–525. doi:10.1016/j.chc.2012.05.002. 
  24. ^ http://www.medicinenet.com/separation_anxiety/article.htm Medicinenet
  25. ^ a b Separation Anxiety Disorder. (n.d.). Retrieved from http://www.childmind.org/en/health/disorder-guide/separation-anxiety-disorder
  26. ^ a b c d e f Silverman, M.D., Wendy K. "Using CBT in the Treatment of Social Phobia, Separation Anxiety and GAD". psychiatrictimes.com. Retrieved 10 December 2014. 
  27. ^ Weems, Carl F.; Carrion, Victor G. (1 July 2003). "The Treatment of Separation Anxiety Disorder Employing Attachment Theory and Cognitive Behavior Therapy Techniques". Clinical Case Studies 2 (3): 188–198. doi:10.1177/1534650103002003002. 
  28. ^ a b Barrett, Paula M.; Ollendick, Thomas H., eds. (2003). Handbook of Interventions that Work with Children and Adolescents: Prevention and Treatment. Wiley. ISBN 978-0470844533. 
  29. ^ Bogels, S. M.; Zigterman, D. (2000). "Dysfunctional cognitions in children with social phobia, separation anxiety disorder, and generalized anxiety disorder". Journal of abnormal child psychology 28 (2): 205–211. 
  30. ^ a b Suveg, Cynthia; Aschenbrand, Sasha G.; Kendall, Philip C. "Separation Anxiety Disorder, Panic Disorder, and School Refusal". Child and Adolescent Psychiatric Clinics of North America 14 (4): 773–795. doi:10.1016/j.chc.2005.05.005. 
  31. ^ a b Waslick, Bruce. "Psychopharmacology Interventions for Pediatric Anxiety Disorders: A Research Update". Child and Adolescent Psychiatric Clinics of North America 15 (1): 51–71. doi:10.1016/j.chc.2005.08.009. 
  32. ^ Brennan, D. (Ed.). (n.d.). Separation Anxiety Disorder in Children. Retrieved from http://www.webmd.com/children/guide/separation-anxiety
  33. ^ Bernstein, Bettina E. Perlstein, David, ed. "Separation Anxiety". WebMD. 

External links[edit]