Separation Anxiety Disorder: Understanding your Child’s Fear

Does your child worry a lot about being apart from a family member or other close people? Do they have a constant fear that something terrible might happen to you or them if you leave them alone? Well, your child may be suffering from Separation Anxiety Disorder (SAD), which is expressed through constant crying, tantrums, or clinginess to a point where you are unable to leave them alone.

Just like adults, children can become anxious at times which can affect their well-being. Research has shown that it is widespread for young children to have anxiety when they are six months to 3 years old (1).

There may also be other times in a child’s life when they feel anxious. For example, many children feel anxious when going to a new school or before tests and exams. Some children feel shy in social situations and may need support with this. However, for some kids, this type of anxiety does not go away and instead, becomes very severe.

It may start to interfere with normal activities like school and friendships, and lasts for months rather than days. Thus, it may be a sign of a more significant problem: Separation Anxiety Disorder(SAD).

Moreover, separation anxiety disorder (SAD) is the most commonly diagnosed childhood anxiety disorder, accounting for roughly 50% of the referrals for mental health treatment of anxiety disorders (2). This article will focus on explaining what Separation Anxiety Disorder(SAD) is, who is likely to get SAD, what the symptoms are, and what treatment options are available.

What is Separation Anxiety Disorder (SAD)?

Separation Anxiety Disorder (SAD) is characterized by “developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached” (3).  Children with SAD become considerably distressed when separated from their parents or family members that they are close with and will try their best to avoid separation. This is a type of fear, as they may think that something terrible may happen to their parent or themselves. In severe cases, their anxiety may lead them to feel that their parent or family member may never return.

Avoidance behaviors related to SAD in children include clinging to parents, crying or tantrums, and refusal to participate in activities that require separation (e.g., play dates, camp, sleepovers). Additionally, these children show oppositional behaviors which can cause disturbance in their family and social functioning, especially school.

Research indicates that children experience separation anxiety disorder (SAD) in their early development, and it diminishes over time. Psychologists and psychiatrists emphasize that a diagnosis of SAD is only given when a child’s distress is inappropriate given their age and their level of development (4). According to the current clinical consensus, it is shown that 4.1% of children will show a clinical level of SAD, and 36.1% of these will carry it in their adulthood (5). 

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Causes of SAD

There are many theories about why separation anxiety disorder (SAD) can develop in children. Researchers believe separation anxiety disorder (SAD) is caused by both biological and environmental influences (6). Common biological factors may include:

  • Child inheriting a tendency to be anxious
  • An imbalance of two chemicals in the brain i.e. norepinephrine and serotonin
  • Insecure attachment. 

A child can also learn anxiety and fear from family members and others around them in their environment. Common environmental causes include:

  • Change in the environment:  This includes moving into a new house, school, or daycare situation, which can trigger separation anxiety disorder.
  • Stress: Stressful situations like changing schools, divorce of parents, or the loss of a loved one—including a pet—can trigger separation anxiety problems
  • An over-protective parent: In some cases, separation anxiety disorder may be the manifestation of their parent’s stress or anxiety. This is a key example of when a child may learn anxious behaviors from their parents or loved ones.
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Signs and Symptoms for SAD

Separation Anxiety Disorder (SAD) is diagnosed by licensed clinical Psychologists and Psychiatrists using the Diagnostic and Statistical Manual (DSM-5). This is a handbook of psychological and mental disorders, which contains descriptions, symptoms, and other criteria for diagnosis (7).

According to the DSM-5, Separation Anxiety Disorder (SAD) is differentiated from regular anxiety as it is consistent and does not go away with development. Common symptoms of Separation Anxiety Disorder (SAD) in children include the following:

  • Denying to sleep isolated
  • Constant nightmares with a premise of separation
  • Constant worry when separated from home or family
  • Constant worry about the safety of a family member
  • Persistent worry about getting lost from the family
  • Refusing to go to school
  • Fearful and unwilling to be alone
  • Regular stomach-aches, headaches, or other physical complaints
  • Muscle pains or tension
  • Too much worry about the safety of self
  • Persistent worry about or when sleeping away from home
  • Being very insecure, even when at home
  • Panic or temper tantrums at times of separation from parents or caregivers

Similar to anxiety, the severity of Separation Anxiety Disorder (SAD) can be different for each child. This depends on the genetic vulnerability and most importantly, the environment they are brought up in. Furthermore, these symptoms of SAD may look like other health problems such as just regular headaches and muscle aches. Thus, make sure your child sees his or her healthcare provider for a proper diagnosis and treatment planning.

Diagnosis and Evaluation of SAD

Even with extension evaluation and thorough examination, a correct diagnosis of SAD can be difficult because other types of anxiety and health problems have similar symptoms. Hence, the following are required for a correct diagnosis of  Separation Anxiety Disorder (SAD) (8).  

  • Diagnostic Interviews: your general practitioner or physician may do an extensive interview session with your child and ask in-depth questions about their worries. They may interview the parents as well if the child is very young. Therefore, the overall goal of this assessment procedure is to enable the clinician to gain precise knowledge of the child’s presenting symptoms, including the frequency, intensity, and duration.
  • DSM-5: Your mental health professional will do a criteria check for separation anxiety disorder (SAD) registered in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), issued by the American Psychiatric Association.

Overall, the mental health practitioner will look for distress triggered by separation and this needs to be excessive for a child’s age. To meet the diagnostic criteria fully, the symptoms mentioned above need to be present for at least four weeks and should cause significant impairment in a child’s social life.

Treatment

There are four types of treatments for children with Separation Anxiety Disorder (SAD): Cognitive Behavioral Therapy (CBT), play therapy, family therapy, and medication. The goal of all these three treatments is to assist children with Separation Anxiety Disorder (SAD) to improve their quality of life psychologically and physically. They also focus on improving their relationships, school, work, and social engagement that previously seemed frozen by their excessive worry. We will now look at each treatment in detail:

  1. Cognitive Behavioral Therapy (CBT): This consists of cognitive restructuring and exposure techniques to reduce anxiety, and enables anxious individuals to cope more effectively with their anxiety. CBT treatments also include psychoeducation for the child and the parents in order to understand the separation anxiety better. Furthermore, the child is taught about breathing retraining and progressive muscle relaxation. The Coping Cat program is a type of CBT used with youth who suffer from anxiety disorders. Research has shown that 6% of the participants who followed the Coping Cat program no longer met criteria for an anxiety disorder (9). Thus, CBT with the Coping CAT program may benefit younger children with Separation Anxiety Disorder (SAD).
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  • Play Therapy: children who are younger than 7 years may find it difficult to identify their thoughts. Thus, a form of play therapy might be useful for them, which uses toys, puppets, games, and art materials for expression of feelings (10). The therapist endorses the child’s feelings and helps them understand the causes. This allows the therapist to provide alternative ways to the child to cope with their separation anxiety.
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  • Family Therapy: This type of therapy is important when family issues are contributing to the child’s anxiety. This intervention includes a parent or sibling participating in addressing how separation anxiety may be coming from within (11). For example, it helps understand if parents are being overprotective and not allowing their child to develop independently. Thus, this type of therapy can reveal a type of parenting style that may or may not be working to help a child with separation anxiety disorder (SAD).
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  • Medications: Research has shown that several medications can be effective in treating separation anxiety disorder; such as the selective serotonin reuptake inhibitors (SSRIs). Standard anxiolytics — or anti-anxiety medications — like the benzodiazepines are also effective (12). However, medications are not usually the preferred treatment type in children due to negative side effects, hence, they are given when all other treatment options have failed.

References

  1. https://www.nhs.uk/conditions/stress-anxiety-depression/anxiety-in-children/
  2. Cartwright-Hatton, S., McNicol, K., & Doubleday, E. (2006). Anxiety in a neglected population: prevalence of anxiety disorders in pre-adolescent children. Clinical psychology review, 26(7), 817–833. https://doi.org/10.1016/j.cpr.2005.12.002
  3. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4. Washington, DC: APA Press; 2000. text rev.
  4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4. Washington, DC: APA Press; 2000. text rev.
  5. Shear, K., Jin, R., Ruscio, A. M., Walters, E. E., & Kessler, R. C. (2006). Prevalence and correlates of estimated DSM-IV child and adult separation anxiety disorder in the National Comorbidity Survey Replication. The American journal of psychiatry163(6), 1074–1083. https://doi.org/10.1176/ajp.2006.163.6.1074 Bottom of Form
  6. Cooper-Vince, C. E., Emmert-Aronson, B. O., Pincus, D. B., & Comer, J. S. (2014). The diagnostic utility of separation anxiety disorder symptoms: an item response theory analysis. Journal of abnormal child psychology, 42(3), 417–428. https://doi.org/10.1007/s10802-013-9788-y
  7. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC:  Author.
  8. Ehrenreich, J. T., Santucci, L. C., & Weiner, C. L. (2008). SEPARATION ANXIETY DISORDER IN YOUTH: PHENOMENOLOGY, ASSESSMENT, AND TREATMENT. Psicologia conductual, 16(3), 389–412. https://doi.org/10.1901/jaba.2008.16-389
  9. Kendall, P. C., Safford, S., Flannery-Schroeder, E., & Webb, A. (2004). Child anxiety treatment: outcomes in adolescence and impact on substance use and depression at 7.4-year follow-up. Journal of consulting and clinical psychology, 72(2), 276–287. https://doi.org/10.1037/0022-006X.72.2.276
  10. Chinekesh, A., Kamalian, M., Eltemasi, M., Chinekesh, S., & Alavi, M. (2013). The effect of group play therapy on social-emotional skills in pre-school children. Global journal of health science, 6(2), 163–167. https://doi.org/10.5539/gjhs.v6n2p163
  11. Schneider, S., Blatter-Meunier, J., Herren, C., In-Albon, T., Adornetto, C., Meyer, A., & Lavallee, K. L. (2013). The efficacy of a family-based cognitive-behavioral treatment for separation anxiety disorder in children aged 8–13: A randomized comparison with a general anxiety program. Journal of Consulting and Clinical Psychology, 81(5), 932–940. https://doi.org/10.1037/a0032678
  12. Hussain, F. S., Dobson, E. T., & Strawn, J. R. (2016). Pharmacologic Treatment of Pediatric Anxiety Disorders. Current treatment options in psychiatry, 3(2), 151–160. https://doi.org/10.1007/s40501-016-0076-7