Separation Anxiety Disorder

Separation anxiety as a normal life stage first develops at about 7 months of age, once object permanence has been established. It is at its strongest at 10-18 months of age and usually subsides by 3 years of age. It is characterized by worrying out of proportion to the situation of temporarily leaving home or otherwise separating from loved ones. Normal separation anxiety may result in parents having trouble with their babies at bedtime or other times of separation, in that the child becomes anxious, cries, or clings to the caretaker.

To understand separation anxiety disorder, it is important to first recognize the normal difficulty that infants and toddlers have with strangers and in separating from parents and caretakers. Infants show stranger anxiety by crying when someone unfamiliar to them approaches. This normal stage of development is connected with the baby learning to distinguish his or her parents or other familiar caretakers from people they don't know.

In addition to the child's temperament, factors that contribute to how quickly or successfully he or she moves past separation anxiety by preschool age include how well the parent and child reunite, the skills the child and adult have at coping with the separation, and how well the adult responds to the infant's separation issues. For example, children of anxious parents tend to be anxious children.

Separation anxiety disorder is a mental health disorder that usually begins in childhood and is characterized by worrying that is out of proportion to the situation of temporarily leaving home or otherwise separating from loved ones. Approximately 4%-5% of children and adolescents suffer from separation anxiety disorder.

Symptoms of separation anxiety disorder may include

• repeated excessive anxiety about something bad happening to loved ones or losing them;
• heightened concern about either getting lost or being kidnapped;
• repeated hesitancy or refusal to go to day care or school or to be alone or without loved ones or other adults who are important to the anxious child;
• persistent reluctance or refusal to go to sleep at night without being physically close to adult loved ones;
• repeated nightmares about being separated from the people who are important to the sufferer;
• recurrent physical complaints, such as headaches or stomachaches, when separation either occurs or is expected.

Examples of behavioral symptoms that children may exhibit to express the anxiety, hesitancy, reluctance, or refusal of events that separate them from loved ones include crying, having tantrums, whining, or begging. Examples of physical symptoms that separation anxiety disorder sufferers may have include stomach upset, headaches, and diarrhea. To qualify for the diagnosis of separation anxiety disorder, a minimum of three of the above symptoms must persist for at least a month in children and adolescents and at least six months in adults, and cause significant stress or problems with school, social relationships, or some other area of the sufferer's life.

Separation anxiety disorder (as with most mental-health conditions) is likely caused by the combination of genetic and environmental vulnerabilities rather than by any one thing.

In addition to being more common in children with family histories of anxiety, children whose mothers were stressed during pregnancy with them tend to be more at risk for developing this disorder.

A majority of children with separation anxiety disorder have school refusal as a symptom and up to 80% of children who refuse school qualify for the diagnosis of separation anxiety disorder. Approximately 50%-75% of children who suffer from this disorder come from homes of low socioeconomic status.

Health-care professionals who have training and experience understanding symptoms of children and adolescents are usually the most qualified to assess separation anxiety disorder. The assessment most often involves a pediatrician and child psychologist, child psychiatrist, or other mental-health professional interviewing both the child and his or her parent(s) when assessing separation anxiety disorder. Those interviews often take place separately to allow everyone to speak freely. This is particularly important given how differently children and their parents may see the situation and how difficult it can be for children to hear their problems discussed. In addition to asking about specific symptoms of anxiety, the professional will likely explore whether the child has symptoms of any other mental-health issues and will recommend that the child receive a full physical examination and lab work to ensure that there is no medical reason for the issues the child is experiencing.

Psychotherapy, medication, and parent counseling are three interventions that have been found to be effective for the treatment of separation anxiety disorder, particularly in combination.

• Counseling, rather than medication, is the treatment of choice for separation anxiety disorder that is mild in severity. For children who either have not improved with counseling alone, suffer from more severe symptoms, have other emotional problems in addition to separation disorder, treatment should consist of a combination of approaches. 
  • Cognitive therapy is used to help children learn how they think and increase their ability to solve problems and focus on the positive things that are going on, even in the midst of their anxiety. By learning to focus on more positive thoughts and feelings, children may become more open to learning strategies to deal with anxiety, such as playing games, coloring, watching television, or listening to music.
  • Behavioral modification therapy is an intervention that directly addresses the behavioral symptoms of separation anxiety disorder. This intervention tends to be more effective and less burdensome to the child if behaviors are addressed positively rather than negatively. The child is not usually punished for continuing to suffer from symptoms but rewarded for small victories over symptoms.
• Relaxation techniques such as imagining themselves in a relaxing situation may be considered more appropriate interventions for older children, adolescents, and adults, even toddlers can be taught simple relaxation techniques, such as imitating their parents, taking deep breaths, or slowly counting to 10 as ways of calming themselves.
• Medication is considered a viable option if psychotherapy is unsuccessful or if the children's symptoms are so severe that they are nearly incapacitating, medication is considered a viable option. Selective serotonin reuptake inhibitors (SSRIs) have been found to be an effective treatment for separation anxiety disorder. Medications that are sometimes considered in treating separation anxiety disorder when SSRIs either don't work or are poorly tolerated include tricyclic antidepressants (TCAs) and benzodiazepines. Benzodiazepines tend to be the least-prescribed group of medications to children suffering from separation anxiety disorder.

Potential complications of separation anxiety disorder include depression and anxiety problems as adults, as well as personality disorders, in which anxiety is a major symptom. Adults with separation anxiety disorder have a guarded prognosis due to their being at risk of being quite emotionally disabled.

Research indicates that educating parents on ways to help their child cope with anxiety may be helpful in the prevention of separation anxiety disorder. Specifically, helping parents guide their child through experiences that cause anxiety, as well as developing healthy ways to cope with such experiences, seems to decrease the likelihood of developing any anxiety disorder, including separation anxiety disorder.

American Academy of Child and Adolescent Psychiatry
3615 Wisconsin Avenue NW
Washington, DC 20016
Phone: 202-966-7300
Fax: 202-966-2891
http://www.aacap.org

American Academy of Pediatrics
141 Northwest Point Boulevard
Elk Grove Village, IL 60007-1098
Phone: 847-434-4000
Fax: 847-434-8000
Email: [email protected]
http://www.aap.org

Anxiety Disorders Association of America (ADAA)
8730 Georgia Avenue, Suite 600
Silver Spring, MD 20910
Phone: 240-485-1001
Fax: 240-485-1035
Email: [email protected]
http://www.adaa.org

National Institute of Mental Health (NIMH), Public Information & Communication Branch
6001 Executive Boulevard, Room 8184, MSC 9663
Bethesda, MD 20892-9663
Phone: 301-443-4513
Toll Free: 1-866-615-6464
TTY: 301-443-8431
TTY Toll Free: 1-866-415-8051
Fax: 301-443-4279
Email: [email protected]
http://www.nimh.nih.gov