Emotional and behavioral disorders in children and adolescents

This card discusses three behavioral disorders that commonly occur in childhood: separation anxiety disorder, selective mutism, and reactive attachment disorder. Reactive attachment disorder is the result of child neglect, whereas the other two disorders do not have a clearly defined etiology. One important diagnostic requirement for both separation anxiety and selective mutism is that the disorders must significantly impair academic and/or social life. Treatment of separation anxiety and selective mutism is focused on behavioral therapy, although drugs such as SSRIs may also be used in severe cases. Treatment in reactive attachment disorder is focused on the caretaker and preventing further child neglect.

• Description: characterized by fear, anxiety, or avoidance of separation from major attachment figures
  • Anxiety associated with separation anxiety disorder differs from normal separation anxiety in its intensity, persistence (beyond the age-appropriate range), and effect on the social and academic life of the individual.
  • Typically develops after a stressful life event, usually involving some form of loss (e.g., death of a relative, parental divorce, change of school)
• Age of onset: childhood (< 15 years of age) ^[1]
• Diagnostic criteria (DSM-5) ^[2]
  • Duration: at least 1 month
  • Developmentally inappropriate and excessive fear about separation from major attachment figures (e.g., parents) or from home
  • Characterized by persistent worrying about losing attachment figures or being without them, with possible complaints of physical symptoms (headaches, nausea/vomiting, abdominal pain) and/or nightmares about separation
  • Significantly impairs academic and/or social life
  • Not attributable to other psychiatric disorders (e.g., autism spectrum disorder, psychosis, anxiety disorders)
• Treatment
  • Psychotherapy: cognitive behavioral therapy, exposure therapy, play therapy, family therapy, parent-child interaction therapy
  • Medications (e.g., fluoxetine) are indicated as an adjunct to psychotherapy if there is moderate to severe functional impairment.
• Complications
  • Often a precursor to school refusal behavior (i.e., the child describes false physical complaints to avoid school)
  • Complications later on in life include depression and substance use disorder.

Separation anxiety is, to some extent, developmentally appropriate for children between 8 months to 4 years of age.

• Description: a relatively uncommon disorder in which children do not speak in particular situations (e.g., the classroom)
  • Development of speech and language usually remains normal
  • May coexist with social anxiety disorder and/or result in school refusal
• Age of onset: : generally occurs by 5 years of age, although usually not diagnosed until the child starts school ^[3]
• Diagnostic criteria (DSM-5)
  • Duration: at least 1 month
  • Child consistently fails to speak in specific situations (e.g., does not speak in class but speaks at home)
  • Interferes with normal life (e.g., social interactions, school, job)
  • Not attributable to language difficulties or other disorders
• Treatment
  • Nonpharmacological: psychotherapy (cognitive behavioral therapy, play therapy, family therapy)
  • Pharmacological: SSRIs (fluoxetine)

• Description: an attachment disorder that is due to abuse and neglect (deprivation) and may be associated with signs of physical maltreatment, undernutrition, excessive appetite/food hoarding, or, if the disorder is severe, growth retardation
  • In contrast to separation anxiety disorders, symptoms occur in a variety of situations, even with strangers.
  • May be associated with aggressive behavior
• Diagnostic criteria (DSM-5)
  • At least 9 months of age developmentally and onset before 5 years of age ^[4]
  • Consistent pattern of inhibited, emotionally withdrawn behavior towards caretakers without seeking comfort when distressed, minimal emotional expression to others, and inadequate care
  • Not due to other psychiatric disorders
• Treatment
  • Behavioral modification for primary caretakers (provision of security, stability, sensitivity)
  • Referral to mental health professionals
  • Medication for comorbid disorders (e.g., depression) if needed

RAD is an internalizing disorder (depressive symptoms, withdrawn behavior), whereas disinhibited social engagement disorder (DSED) is an externalizing disorder (disinhibition, overfamiliarity with strangers).

• Description: A childhood attachment disorder that is characterized by uninhibited interactions with unfamiliar adults and associated with emotional neglect during infancy.
• Diagnostic criteria (DSM–5)
  • Consistent pattern of disinhibited behavior characterized by at least two the following:
    • Lack of restraint in approaching and engaging with unfamiliar adults
    • Excessively familiar behavior towards strangers that is inconsistent with age-appropriate or culturally accepted norms
    • Venturing away without checking back with adult caregiver, even in unfamiliar settings
    • Little or no hesitation to accompany unfamilar adults away from caregiver
  • A history of severely insufficient or inconsistent childcare in early childhood (< 2 years of age) ^[5]
  • Not due to other psychiatric disorders (e.g., impulsivity in ADHD)
  • Developmental age of at least 9 months
• Treatment ^[5]
  • Child-parent psychotherapy
  • Family therapy
  • Coaching techniques for primary caregivers