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Separation Anxiety Disorder (SAD) in children, It is an anxiety disorder characterized by excessive fear of being separated from an attachment figure. Patients diagnosed with SAD experience irrational and illogical anxiety if they are distanced from home or persons to whom they have a strong relationship (e.g. parents, caregivers, etc.). Anxiety disorders are prevalent among young people and children. It is estimated that around 5-25% of young people have anxiety disorders worldwide, but the majority of patients do not receive treatment. Cartwright-Hatton et al. showed that among all anxiety disorders, Separation anxiety disorder (SAD) accounts for approximately 50% of the cases. Based on the DSM-IV-R diagnostic criteria, SAD should last more than one month, lead to considerable problems, interfere and affect daily activities, occur before the age of 18, and go beyond what is expected from the child. SAD leads to considerable impairment in children's life.

Symptoms
Children with SAD experience some of the following symptoms :


 * ·a chronic sorrow or extreme anxiety when they experience a real or imagined separation from their attachment figures.
 * A considerable apprehension about losing an attachment figure or any possible danger occurs to them (e.g. car accident, death, disease, etc.).
 * They refuse to leave home since they are afraid of separation.
 * Physical symptoms when they are distanced from their attachment figures (e.g. stomachaches, headache, and vomiting).
 * Nightmares about separation.
 * Rejection to sleep away from an attachment figure.

the brain mechanism:


Ledoux has shown that anxiety leads to Stress response, which in turn unleashes a  variety of neurotransmitters  Catecholamines  including epinephrine, dopamine, and norepinephrine into the nervous system. These neurotransmitters stimulate the heart muscle and may affect the stomach, which in turn leads to a fight or fight  scenario. They also activate the amygdala (The brain component that controls fear emotions. On the other hand, they may deactivate the prefrontal cortex (the brain component that controls thinking patterns).

Stress also affects hippocampus (the brain region that is responsible mostly for memory and learning). According to a recent study, hippocampus becomes smaller if individuals experience stressful events. They also experience considerable deterioration in memory abilities.

Family history:
As reported by a recent study, mothers, who had disturbed attachments with their caregivers, tend to develop responses to their babies' normative social bids, which in turn lead to malfunctioning social referencing. These responses are associated with mothers' psychopathology (Depression and maternal PSDT). According to the Social learning theory, humans form habits and learn by observing others in their environment, which in turn highlights the role of family history in SAD sustainability.

Environmental issues:
Individuals, who have a previous traumatic separation from a caregiver, are more likely to experience SAD, school phobia, or depressive spectrum disorders.

Life stressors or a traumatic loss:
It includes risk factors such as death or illness of a loved one, the death of a pet, and parents' separation.

Genetics:
Genetics may lead to development and sustainability of SAD. A recent study has shown that heritability accounted for 73% of the community sample cases. The rates were higher among girls who took part in the study.

Diagnosis
SAD is normal between the early months of childbirth until two years of age(3). Other studies suggest that it is normal until they reach the age of three or four when they are left in a preschool or a daycare away from their primary caregiver or mother. Based on a recent study, children who left their country at an early age may experience SAD, since they felt separated from their home country, friends, and families. This effect aggravates if they unfamiliar with the language spoken in the new place. In these circumstances, SAD symptoms may disappear as they get accustomed to the new environment. It is diagnosed as a disorder only if the anxiety level exceeds the normal limit that meets the child's age and developmental level, and if it negatively affects the child's life.

To be diagnosed with separation anxiety disorder, children should meet at least three of the aforementioned SAD symptoms(28).

Classification
One of the main difficulties in diagnosing SAD is that it is extremely comorbid with other disorders (e.g. GAD). SAD symptoms including School refusal or homesickness can point out to other disorders, which in turn poses a challenge in diagnosing SAD. For instance, common co-morbidities may involve PTSD, panic disorder, Obsessive-Compulsive Disorder (OCD), specific phobias, and personality disorders, which in turn manifest the need for a comprehensive assessment of the patient to differentiate between the similarities and differences. A significant indicator to distinguish between separation anxiety disorder and other mental disorders is to check the origin of the child's fear.

Assessment techniques
They include self-reports, monitoring mother-child relationship, diagnostic interviews from both the child and the mother, and assessment of Preschool children. Many aspects of patient's development should be inspected such as medical issues, social life, sleep and feeding schedules, past traumatic events, and family history. Inspection of the child's life assists in giving a comprehensive understanding of the child's life. Clinicians need to interview (e.g. (ADIS-IV-C/P), (DISC-IV), and (K-SADS-IV)) the mother and child separately to inspect all essential details and information to help them have a full understanding.

Self-reports:
For fully-developed children who have communication and cognitive skills, this method may be helpful.

Monitoring:
Clinicians need to monitor children in different environments and situations (e.g. daycare, home, and preschool). They also need to observe and monitor interactions between child and parent and spot any behaviours that may promote SAD.

early diagnosis at the preschool stage:
The Preschool Age Psychiatric Assessment (PAPA) is a common tool to identify children with SAD (ages 2-5). It is also beneficial to interview preschool children. Common interviews include Emotional Knowledge and Doll-Play. The interviews include a separation and reunion scenario, this is followed by showing four facial expressions, and the child is asked to point at one of which. Analysing the results helps to fully comprehend the child's current mental state.

Psycheducation:
It is essential to establish a strong cooperation between patient, family, and the therapist, which in turn contributes to an effective SAD treatment. Psychoeducation can be carried out by educating the child (according to his cognitive skills) and the family, promoting motivation and insight.

Psychoeducation needs to include the following:


 * Anxiety is normal behaviour.
 * Gain a well understanding of Anxiety triggers
 * Prognosis
 * Treatment alternatives (pros and cons).

Behavioural management:
It is the most suitable treatment for mild cases of SAD. Family members and caregivers are informing, how to handle malfunctioning attitudes and mild symptoms (e.g. avoidance behavior). If it fails to reduce SAD symptoms, it should be accompanied with other treatment strategies. Behavioral Management aims to establish a supportive and flexible environment to contribute to SAD treatment.

Intervention at home:

Therapists are recommended to encourage parents to do the following:

·        Parents should stay quiet when their child is anxious, which in turn helps to model the behavior of the child.

·        Parents need to remind the child that he was able to survive a similar anxiety-provoking situation before.

·        Teaching children how to relax (e.g. Deep breathing).

Intervention at school:

·        Schedule regular meetings with parents to promote collaboration and coordination.

·        Inspect the core reason for school refusal and plan how to avoid it.

·        Determining a safe place where the child feel safe in case of stressful periods

·        Encourage Classroom interactions

Cognitive-behavioral therapy (CBT):
Many studies have shown that CBT is very effective in anxiety treatment, including SAD. Studies also have shown that CBT is the first line treatment for dealing with anxiety disorders. On the other hand, medication may suit severe cases. The CBT treatment duration depends primarily on the case severity, response, and treatment design.

CBT seeks to :


 * Dominate worries.
 * Minimise arousal.
 * Acquire a comprehensive understanding of the origin and presence of SAD symptoms.
 * Stand up against and challenge the feared situations/scenarios.

CBT treatment includes the following to achieve the goals above :


 * Cognitive restructuring (Minimizing negative thoughts and self-talks, among other methods)
 * Relaxation, which in turn helps to reduce physical symptoms.
 * Contingency management.
 * Modelling.
 * Exposure and response prevention.

Exposure and response prevention:
It is the main component of CBT treatment for dealing with all forms of anxiety. The therapist asks the child to list the anxiety triggers, which in turn helps to establish an initial description of symptoms, and they will assist later in the treatment development. The child is asked to rate every situation for the degree of avoidance and fear on a Likert scale. The Likert scale is designed to match the cognitive level of the child. The second stage is to disrupt the escape patterns that perpetuate anxiety for a long time. The child is then exposed progressively to fear-inducing triggers, which in turn helps to reduce the severity of the symptoms. Category:Developmental psychology