Disease Description (Causes and Symptoms)
- Definition: An anxiety disorder characterized by excessive anxiety about separation from an attachment figure (caregiver) that is disproportionate to the person’s age and causes significant impairment in daily functioning. The prevalence in children and adolescents is approximately 4%, and it commonly appears around 7–8 years of age.
- Causes and pathophysiology: Genetic and temperamental vulnerability, overprotective or anxious parenting styles, a family history of anxiety disorders, and stressful events such as moving, bereavement, or starting school may contribute. Neurobiologically, hyperactivation centered on the amygdala, which is involved in fear and threat processing, and reinforcement of avoidance behaviors may be associated with the disorder.
- Main symptoms: Refusal to separate from a caregiver, refusal to attend school or overnight events, excessive worries about separation (concerns about the caregiver’s safety and fear of being unable to reunite), sleep disturbances, physical symptoms such as palpitations, dizziness, headache, and abdominal pain, clingy behavior (constantly checking or calling), and an abnormally intense fear of separation for the person’s age.
Treatment Methods
- First-line treatment: Cognitive behavioral therapy (CBT)—particularly family-based CBT including gradual exposure and parent training—is recommended as the standard treatment. Examples of goals include gradually being alone outside the home, attending school, and sleeping alone.
- Adjunctive psychotherapy: Play therapy, supportive counseling, and family therapy (correcting parenting attitudes and establishing consistent rules).
- Medication: In severe cases or when improvement with psychotherapy is insufficient, SSRIs (e.g., fluoxetine, sertraline) may be considered. In children and adolescents, medication must be prescribed by a psychiatrist after evaluating the indication, dosage, and monitoring requirements. Benzodiazepines and similar medications are not recommended for use other than short-term use.
- Lifestyle management: Maintain regular sleep and meals, minimize stressors, develop a gradual return-to-school plan in cooperation with the school and teachers, and respond consistently while avoiding excessive checking or rewards (such as allowing excessive phone calls).
- Precautions and risk of complications: Without early treatment, school refusal, reduced academic and social functioning, possible comorbid anxiety disorders or depression, and the possibility that separation-related difficulties may persist into adulthood can occur. When medication is used, side effects such as gastrointestinal symptoms, insomnia, and behavioral changes should be monitored.
Checklist Before an Outpatient Visit (Including Preparation Items and Example Questions)
- Items/materials to prepare
- A list of current medications, including prescription drugs, over-the-counter medicines, and supplements
- A record of when the symptoms began and their course (when they occur, how often, and how long they last)
- Records of school refusal or absences and school reports, if available
- The frequency and characteristics of physical symptoms (such as headaches and abdominal pain), along with recent medical history and test results (internal medicine visits and test results)
- Family history (anxiety, depression, and psychiatric diagnoses) and recent stressful events (such as moving or bereavement)
- Previous treatment (history of psychotherapy, medication prescriptions, and their effects and side effects)
- Examples of useful symptom records for the visit
- Behaviors during separation (crying, resistance, and physical symptoms), duration, and situations or activities avoided (school, friends, overnight stays, etc.)
- Situations that worsen or relieve symptoms (phone calls, lunchtime, etc.)
General Example Questions to Ask the Doctor
- "What treatment options are recommended for this condition? What should be prioritized?"
- "If medication is needed, which medication would be used, and what are its side effects?"
- "After starting treatment, when does improvement usually begin? What is the prognosis?"
- "What practical support can the family or school provide to help with returning to school?"
Examples of Condition-Specific Questions
- "How is a gradual exposure plan structured specifically (for example, the preparation process for a school trip or camp)?"
- "If medication treatment is started, how long does it usually need to be taken, and how should discontinuation be planned?"
Additional guidance: If symptoms are severe or there is school refusal, severe physical symptoms, or impaired daily functioning, consultation with a child and adolescent psychiatrist or psychiatrist is recommended as soon as possible.