Separation Anxiety Disorder
Separation Anxiety Disorder
Like many childhood concerns, separation anxiety is normal at certain developmental stages. For example, when a child between the ages of eight and 14 months is separated from her mother or other primary caretaker, she may experience distress. This is normal. However, separation anxiety that occurs at later ages is considered a disorder because it is outside of normal developmental expectations, and because of the intensity of the child’s emotional response. Separation anxiety disorder occurs most frequently from the ages of five to seven and from 11 to 14.
Environmental stimuli and internal cues from the child himself interact in the presentation of separation anxiety disorder. Separation anxiety disorder is defined by the primary expression of excessive anxiety that occurs upon the actual or anticipated separation of the child from adult caregivers—most often the parents. Significant problems in daily functioning for the child and parents can result from the disorder. Common fears observed in the presentation of separation anxiety include concerns about the parents’ health or well-being (less frequently the child’s own health), general catastrophes, natural disasters, or the child becoming lost/separated from the parents. Disrupted sleep, difficulty falling asleep alone, fear of monsters, or nightmares are also commonly experienced by children with separation anxiety disorder.
Family routines, parents’ work schedules, and siblings’ activities may all be negatively affected by the excessive anxiety and demands of the child with separation anxiety disorder. Family life is often disrupted by efforts to soothe the child. Parents can become stressed themselves as they try to maintain their daily routines and obligations, while attempting to manage their child’s anxiety. The family’s adjustment is often made more difficult due to the sudden appearance of symptoms.
Children experiencing separation anxiety disorder display significant distress upon separation from the parent or other primary caregiver. Separation anxiety disorder often becomes problematic for families during elementary school, although it can also occur in older or younger children. The child appears fearful because he or she thinks something horrible will happen to the child or parent while they are apart. The child’s responses to separation may include crying or becoming angry with the adult in an attempt to manipulate the situation. When thwarted by the adult’s appropriate boundaries, expectations, and structure (the child must attend school, for example), the child’s distress may become displaced into other maladaptive or negative behaviors. The child may begin to exhibit behavioral problems at school or at home when there has been no previous history of such problems. The child may seek out a new, negative peer group in order to gain attention or avoid separation.
Many children are unable to describe their specific fear. The feelings may seem more general and engulfing, especially to the younger child, making description more difficult and the feelings more overpowering. Children, and even adolescents, may experience difficulty describing their internal thoughts and feelings, which is normal. The ability to self-monitor, or observe one’s own behavior or decision-making process, doesn’t develop until late in adolescence for some individuals. When caregivers press the child experiencing separation anxiety for explanations, the feelings of anxiety can actually become more overwhelming. The intensity of the child’s emotional response, accompanied by a lack of explanation, can become very frustrating for parents. Children or adolescents with an angry or frustrated parent may create a reasonable explanation for their fears to appease caregivers, and to keep them from leaving. Lying to take the emphasis off their strong feelings may be one of the early behavioral changes that can accompany separation anxiety.
Although exposure to a specific stressor is not required for the development of separation anxiety disorder, in many cases, a specific incident may precipitate the onset of the disorder (the traumatic events of September 11, 2001, for example). Another common precipitant is the holiday or summer break from school. Some children experience significant difficulty returning to school after a relatively short break, but certainly after summer and holidays.
- Environmental change. Separation anxiety disorder is often precipitated by change or stress in the child’s life and daily routine, such as a move, death or illness of a close relative or pet, starting a new school, a traumatic event, or even a return to school after summer vacation.
- Genetic influence. Evidence suggests a genetic link between separation anxiety disorders in children and a history of panic disorder, anxiety, or depression in their parents. Infants with anxious temperaments may have a predisposition toward later development of anxiety disorders.
- Parent/child attachment. Quality of attachment between children and their parents has also been identified as a factor in separation anxiety disorder. If the child senses emotional distance, the behaviors may be an attempt to draw the parent in more closely. The problematic behaviors can also draw the attention and care of others as well.
- Developmental considerations. Children develop at different rates when compared to each other (boys mature slower than girls, for example). Furthermore, the rate of development within the same person can vary across different types of functioning (for example, a gifted child is advanced intellectually but may be behind developmental expectations for social and emotional areas of functioning). A slower rate of development in the intellectual, social, emotional, or physical arena can foster anxiety within the child, making the separation more difficult.
- Cognitive factors. Children repeatedly worry about what they are afraid of (getting lost or a parent getting hurt, for example). The thought patterns are repeated within the child’s mind until his emotions are beyond his control. The child may feel he is unable to think about anything else other than his fears, which contributes to his anxiety and irrational behaviors.
- Behavioral factors. The child or adolescent’s crying and clinging behaviors may be developed by the child to cope with the feelings of anxiety associated with certain people, environment, or situations, such as attending school. The behaviors serve to distract attention away from the child’s negative feelings, while nurturing the anxiety and fear into a greater part of the child’s daily experience. For children, the behavioral component often becomes the mode of expression for the anxiety. The behavior may appear manipulative at times, due to the quick disappearance of symptoms once the threat of separation passes.
- Stress factors and influence. Symptoms of separation anxiety disorder may be exacerbated by a change in routine, illness, lack of adequate rest, a family move, or change in family structure (such as death, divorce, parent illness, birth of a sibling). The child’s symptoms may also be affected by a change in caregivers or changes in parents’ response to the child in terms of discipline, availability, or daily routine. Even if changes are positive or exciting, the change may feel uncomfortable and precipitate an anxious response in the child.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR),a handbook for mental health professionals that aids in diagnosis, lists the following criteria for separation anxiety disorder.
- Recurrent excessive distress upon separation. The child may become focused on the separation long before the actual event, or simply at the time of the anticipated separation. The recurrent behavioral pattern does not respond to intervention. The child experiences extreme distress, a highly charged emotional response that is repeated when the child anticipates separation from the caregiver. The child’s fears trigger more anxiety and the emotional response intensifies.
- Persistent and excessive worry. The content of the worry may include some type of harm occurring to the child himself or toward the parents, or it may focus on becoming lost or separated indefinitely from the parent or caregiver.
- Repetitive nightmares. The child may experience repeated nightmares with themes of being chased, harmed, or separated from her family. Some fears are age-appropriate, but in separation anxiety disorder, the intensity of the fears becomes overwhelming to the child, leaving little opportunity for the child to control her emotions or behaviors. Although dreams are often a way of exploring and making sense of daily life, children with separation anxiety disorder report nightmares that represent their irrational fears or preoccupation with disaster.
- Complaints of physical symptoms. The child may feign illness (headaches, stomachaches, etc.) to avoid separation, or the child may actually experience nausea upon separation. If allowed to continue, the child may develop psychosomatic symptoms (physical symptoms with a psychological origin) that prevent the child from attending or fully participating in school activities. In these cases, the separation anxiety may develop into a more serious hypochondriacal state in which the child complains of chronic pain, which results in the child getting what she wants (i.e., not attending school).
- Persistent reluctance or refusal to engage in age-appropriate activities. The child may refuse to attend school because of preoccupation about separation from the parent. The child may also experience reluctance to be alone at home or at school without another adult being immediately available. The child may resist sleep without an adult present. The disorder causes significant disruption in the child’s daily routine and may decrease the ability to perform previously mastered tasks. The child may appear to have reverted to behaviors from a younger age. The intensity of her emotions blocks the child’s ability to communicate her feelings in ways other than through behaviors. Examples include tantrums, hitting, or clinging. Crying is one of the primary behaviors associated with separation anxiety disorder. The crying can become quite intense, making it difficult for the child to regain composure.
- Enmeshment or unusual interest in parents’ schedules. The child wants to know all the details of the daily routine, a behavior which minimizes the anxiety the child is feeling.
- Quick resolution of symptoms (upon meeting child’s demands). It may be hard for parents to accept the reality of the disorder because the symptoms often disappear quickly when separation does not occur. It is this component that can feel manipulative to those in the child’s life.
Prevalence estimates of separation anxiety disorder are 4-5% of the population. Gender differences have not been observed, although girls do present
more often with anxiety disorders in general. Of those diagnosed with separation anxiety disorder, approximately 75% experience school refusal. The most frequently observed ages for occurrence of separation anxiety disorder are in children ages five to seven years and again from ages 11 to 14 years. It is at these times the children may feel more challenged by the developmental tasks of entering school or beginning puberty.
The mental health professional will usually make the diagnosis of separation anxiety disorder based on information gathered during an interview process involving the parent(s) and the child. It is usually preferable for the interviews with the parent and child to occur separately; however that may not be possible because of the child’s intense anxiety about separation.
As noted, separation anxiety disorder is generally diagnosed by history, including parental report; however, a few measures of general anxiety exist that can be used to supplement the history. These include Pediatric Anxiety Rating Scale, Children’s Global Assessment Scale, Children’s Anxiety Scale, Screen for Child Anxiety Related Emotional Disorders (SCARED-R), Multi-Dimensional Anxiety Scale for Children, and Achenbach’s Child Behavior Checklist.
Duration of disturbance prior to diagnosis is a minimum of four weeks, occurring prior to the age of 18 years.
The disorder is described as “early onset” prior to the age of six years, and is generally not diagnosed after the age of 18. However, some researchers are describing another type of separation anxiety experienced by parents when their adolescents leave home. Readers may recognize this stage of life as the “empty nest syndrome,” however, no such formal diagnosis exists for a parental form of separation anxiety.
The most effective treatments for separation anxiety disorder involve parents, as well as school personnel when appropriate. Giving the child a sense of safety and security is key to successful treatment. Current treatment methods combine some form of group or individual cognitive behavioral intervention. A number of treatment options are discussed below.
Cognitive-behavioral therapy is a treatment approach designed to alter a person’s thoughts, beliefs, and images as a way of changing behavior. In treating a child with separation anxiety disorder, the goal is to help the child label her fears and identify the irrational beliefs and assumptions underlying her fears. By confronting and correcting her false beliefs, a parent can help his or her child become less anxious about separation.
With imagery, a child uses his imagination to see himself being successful in a stressful situation. For example, before heading off to school, a child could imagine how he will handle separation from mom. Instead of crying, he sees himself calmly saying goodbye to his mom. The use of positive mental pictures may help diminish some of the child’s anxiety and fear before separation actually occurs.
Parents and teachers can be helpful in modeling appropriate behaviors and coping mechanisms at home and at school. For example, parents can model being relaxed when saying goodbye to their children and other people.
Systematic desensitization is a behavior modification technique in which a person is gradually exposed to an anxiety-provoking or fearful object or situation while learning to be relaxed. A child with separation anxiety disorder may be taught to spend longer and longer periods of time at school without a caregiver present by teaching her relaxation techniques for managing her anxiety.
Positive role models
Using positive role models, whether in real life or in books, can also be helpful for children. Reading books about other children successfully separating from their caregiver can give the anxious child the confidence that he can do it, too. Watching his friends calmly separate from their caregivers can also empower the child to do the same.
Behavior modification uses a system of rewards and reinforcements to change behavior. This method has been shown to be effective in a majority of cases
involving children and separation anxiety disorder, even at one-year follow-up.
Small items that remind the child of his bond with his parents can sometimes be helpful in managing the child’s anxiety. Typical objects could include a smooth stone in the child’s pocket, a picture of the family in the child’s notebook, or a friendship bracelet. Allowing phone calls or contact throughout the day is generally not effective, as it provides a more direct reminder of the caregiver’s absence.
Distraction and altruism
Distraction and altruism is another strategy that can be useful in treating separation anxiety disorder. Helping the child focus on things outside himself can provide a healthy distraction. For instance, the child may be asked to take care of a pet at school. Such distractions from the child’s internal thoughts and feelings coupled with a “fun” responsibility can help the child move away from his internal state of anxiety.
Medication is helpful in certain cases where the anxiety is so debilitating that the child is unable to participate in other forms of treatment, or go about his daily routine. Medication management most often involves some type of anti-anxiety or anti-depressive drug. The newest classes include the SSRIs or selective serotonin re-uptake inhibitors that influence neuro-transmitters in the brain to regulate emotional response. Before any medication is given, however, it is essential that a careful medical and psychiatric evaluation be performed by a trained health professional.
More than 60% of children participating with their parents in cognitive-behavioral treatment are successful in managing their symptoms without medication. Symptoms generally do not re-appear in exactly the same way as the initial presentation; however, the child may have a heightened sensitivity to normal life transitions, such as changing schools. Families can help children cope with these transitions by visiting the new school, meeting teachers, and getting to know some students.
Separation anxiety disorder has a poorer prognosis in environments where threat of physical harm or separation actually exist.
Existence of other conditions, such as autism, decrease the likelihood of a positive prognosis. Presence of separation anxiety disorder in childhood is sometimes associated with early onset panic disorder in adults.
Neurotransmitter —A chemical in the brain that transmits messages between neurons, or nerve cells.
Studies indicate a lower prevalence of alcohol use and suicidal ideation in children or adolescents who experience separation anxiety disorder. Depression is commonly associated with anxiety disorders. Developing social skills can also be negatively affected by separation anxiety disorder.
Prevention can be enhanced through parent effectiveness training that emphasizes the child’s positive and successful coping strategies when dealing with separation. Overly anxious parents may need to develop their own support mechanisms and systems to manage their feelings and avoid influencing their children negatively.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.
Burke, P., R. C. Baker. “Is fluvoxamine safe and effective for treating anxiety disorders in children?” Journal of Family Practice 50, no. 8 (2001).
Goodwin, R., J. D. Lipsitz, T. F. Chapman, S. Mannuzza, and A. J. Fyer. “Obsessive-compulsive disorder and separation anxiety co-morbidity in early onset panic disorder” Psychological Medicine 31, no. 7 (October 2001): 1307-1310.
Kaplow, J. B., P. J. Curran, A. Angold, E. J. Costello.; “The Prospective Relation between Dimensions of Anxiety and the Initiation of Adolescent Alcohol Use.” Journal of Clinical Child Psychology 30, no. 3 (2001): 316-326.
Kendall, P.C., E. V. Brady, T. Verduin. “Comorbidity in Childhood Anxiety Disorders and Treatment Outcome.” Journal of the American Academy of Child & Adolescent Psychiatry 40, no. 7 (2001).
Muris, P., B. Mayer, E. Bartelds, S. Tierney, and N. Bogie. “The revised version of the Screeen for Child Anxiety Related Emotional Disorders (SCARED:R).” British Journal of Clinical Psychology 40 (2001): 323-336.
Shortt, A. L., P. M. Barrett, T. L. Fox. “Evaluating the FRIENDS Program: A Cognitive-Behavioral Group Treatment for Anxious Children and Their Parents.” Journal of Clinical Child Psychology 30, no. 4 (2001): 525-535.
Southam-Gerow, M. A., P. C. Kendall, V. R. Weersing. “Examining Outcome Variability: Correlates of Treatment Response in a child and Adolescent Anxiety Clinic.” Journal of Clinical Child Psychology 30, no. 3 (2001): 422-436.
Walkup, J. T., M. J. Labellarte, M. A. Riddle, Daniel S. Pine, L. Greenhill, R. Kelin, M. Davies, M. Sweeney, H. Abikoff, S. Hack, B. Klee, J. McCracken, L. Bergman, J. Piacentini, J. March, S. Compton, J. Robinson, T. O’Hara, S. Baker, B. Vitiello, L. A. Ritz, M. Roper. “Fluvoxamine for the Treatment of Anxiety Disorders in Children and Adolescents.” The New England Journal of Medicine 344, no. 17 (2001).
American Academy of Child & Adolescent Psychiatry. www.aacap.org
Anxiety Disorders Association of America. 11900 Parklawn Drive, Suite 100, Rockville, MD 20852. Phone: (301) 231-9350. Web site: www.adaa.org
Brandt, Amy, Eida de la Vega, and Janice Lee Porter. Benjamin Comes Back. Saint Paul: Redleaf Press, 2000.
Penn, Audrey, Ruth E. Harper, Nancy M. Leak. The Kissing Hand. Washington: Child Welfare League of America, Incorporated, 1993.
Deanna Pledge, Ph.D.