• Clinical science

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.

Separation anxiety disorder

Separation anxiety disorder is 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.

  • Age of onset: childhood, with mean onset at 7.5 years
  • Diagnostic criteria (DSM-5)
    • Duration: at least 1 month
    • Developmentally inappropriate and excessive fear about separation from major attachment figures (e.g., parents)
    • Characterized by persistent worrying about losing attachment figures or being without them, with possible complaints of physical symptoms (headaches, nausea/vomiting) and/or nightmares about separation
    • Significantly impairs academic and/or social life
    • Not attributable to other psychiatric disorders (e.g., autism spectrum, psychotic, or anxiety disorders)
  • Treatment
  • Complications
    • Often a precursor to school refusal behavior
    • Complications later on in life include depression and substance use disorder.

Separation anxiety is normal between 8 months to 4 years of age!


Selective mutism

Selective mutism is a relatively uncommon disorder in which children do not speak in situations when speech is expected. It 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
  • Diagnostic criteria (DSM-5):
    • Duration: at least 1 month
    • Child consistently fails to speak in specific situations
    • Interferes with normal life (e.g., social interactions, school)
    • Not attributable to language difficulties or other disorders
  • Treatment: SSRIs; (fluoxetine) and cognitive behavioral therapy


Reactive attachment disorder

Reactive attachment disorder (RAD) is 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, and may be associated with aggressive behavior.

  • Diagnostic criteria (DSM-5):
    • At least 9 months of age developmentally and onset before 5 years of age
    • 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)!