3% had no comorbid condition while the rest (15.7%) had atleast one comorbid condition. These subjects also showed a higher SASI score (p = .053). The subgroup with comorbid condition also showed a history of early onset (p < .01) and poor recovery of global functioning (p < .05) when compared to the non-comorbid group. Female subjects also showed higher SASI score (p < .05). This study clearly shows a positive association between childhood separation anxiety disorder and the onset of co morbid psychological conditions in adult life. Particularly, women with childhood separation anxiety disorder were more prone to develop a continuum of disorders in adult life. [Akira et.al, 2006] A more recent study by Karlovec et.al (2008) followed 10 Austrian students who had a previous history of separation anxiety and school refusal. All the subjects in the study had undergone 12 weeks of cognitive behavioral therapy at the Innsbruck Medical University, Austria, as treatment for separation anxiety disorder. During this follow-up study, the children were aged between 9 to 14 years. The study involved a series of interviews with the parent and the children pertaining to the history of separation anxiety and school refusal. The subjects were evaluated for separation anxiety and other psychiatric disorders using the 'Diagnostic Interview for Mental Disorders in Children and Adolescents' based on the DSM-IV criteria. Analysis of the gathered data revealed that the cognitive behavioral therapy was successful in overcoming school refusal among the students with only one subject continuing to exhibit symptoms of school refusal. However, the results of the study also indicated that all the subjects had atleast 2 psychiatric conditions (based on the DSM -- IV criteria), with some students having 3, 4 or 5 co morbid disorders. Attention deficit hyperactivity disorder (N=6), oppositional defiant disorder (N =4) and agoraphobia (N=3) and obsessive compulsive disorder (N=3) were the other psychiatric co morbid conditions. Overall, 3 subjects were totally recovered while 6 others were in partial remission. This study suggests that children who are school refusers and diagnosed with separation anxiety disorder are at a greater risk for developing other co morbid psychiatric disorders. The study also indicated that children who are successfully treated for separation anxiety might require further monitoring and intervention for other possible psychiatric conditions. [Karlovec et.al, 2008]

Lewinsohn et.al (2008) is another research that studied the predisposition of children diagnosed with SAD at childhood for other psychiatric disorders during adolescence and adulthood. Subjects were chosen from the Oregon Adolescent Depression Project (n = 816). This was a longitudinal study where the subjects were screened for childhood history of SAD, current mental illnesses (at 16 years of age) and followed up into adulthood up to the age of 30. The subjects were assessed twice during adolescence and the diagnostic assessments were repeated again at 24 and 30 years of age respectively. The subjects were divided into four groups SAD (n = 42), other psychiatric disorders (n = 88), 'heterogeneous psychiatric disorders control group' (n = 389) and a control group without any mental disorders (n= 297). Statistical analysis of the data using multiple logistic regression revealed that SAD was a high risk factor (78.6%)for developing other psychiatric conditions. In particular, children with SAD had a high propensity for developing depression and panic attack in their adolescent and adult lives. The results of this study again emphasize the importance of treating SAD promptly not only for its remission but also for its effectiveness in controlling the development of future psychopathology. [Lewinsohn et.al (2008)]

Treatment of SAD

The effective management of SAD involves a multimodal treatment that involves cognitive behavioral therapy, family based therapy and pharmacological therapy. Cognitive behavioral therapy is singled out as the best intervention for SAD. Studies have shown significant drop in truancy rates with as much as 83% of the subjects who underwent the therapy successfully...

(Assessed a year after the therapy) Cognitive therapy aims at a restructure of the perceptions of the child about separation. It aims to identify the underlying somatic symptoms and to successfully deal with them. Pharmacological interventions are not preferred as a general case for the management of SAD, but if the symptoms are severe and they impede with the normal functioning of the child pharmacological intervention might be added to manage it better. Fluoxetine or Prozac is the only drug (a selective serotonin reuptake Inhibitor) that is approved by the FDA for use in children below 12 years of age. Other SSRI drugs are generally avoided, as they are known to cause side effects such as suicidal ideation, aggression, etc. Family based therapy aims to identify any pre-existing psychiatric conditions in members of the family. Family therapy involves counseling to the members of the family so as to identify and remove and damaging and disruptive behavioral patterns in the family that may affect the Childs normal development. [Bettina E. Bernstein]
Conclusion

Separation anxiety is a very natural reaction and very much a part of the normal cognitive development of a child. It is part of the normal bonding process between the child and the parents. However, separation anxiety disorder is an abnormal condition where there is excessive anxiety, which is far beyond the normal level for the particular stage of development of the child. Over protective parenting style, depressed parents, or other environmental stressors such as early loss of parents or close persons are all high risk factors that may make a child vulnerable for separation anxiety disorder. As several studies discussed above, separation anxiety disorder is a precursor for several psychiatric conditions much later in the adult life. Thus it is important to treat SAD promptly not only for its remission but also for its effectiveness in controlling the development of future psychopathology. A multimodal treatment program involving cognitive behavioral therapy, family based therapy, and appropriate pharmacological intervention if necessary, is the best therapeutic approach to effectively manage separation anxiety disorder.

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