Mental Health Guide

Separation Anxiety Disorder

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What is it?

Separation anxiety disorder is a condition that causes a child or adolescent extreme distress when she is separated from her parents or caregivers. Difficulty separating is normal in early childhood development; it becomes a disorder if the fear and anxiety interfere with age-appropriate behavior, whether it’s an 18-month-old who can’t bear to be out of sight of his mother or a 7-year-old who can’t tolerate a school day apart from his parents. Symptoms of separation anxiety disorder commonly become noticeable in pre-school and early grammar school, but in rare cases it becomes problematic later, in early adolescence. An estimated 4% of children have the disorder, which is very treatable with both behavioral and pharmacological therapies, particularly when it is caught early. 

What to look for

Key warning signs that a child may have separation anxiety disorder are extreme overattachment to parents and a persistent perception that the family is in danger when separated from the child. A child might have a hard time saying goodbye to parents, being alone on one floor of the house, or going to sleep in a darkened room, because she is terrified that something will happen to her or her family. She might also have physical symptoms that manifest in anticipation of separation, including stomachaches, headaches, and dizziness. If she's at school, she may feel an overwhelming need to know where parents are, and to be in touch with them by phoning or texting.

 

These symptoms, combined with the fear, can lead to extended absences from school; children with this disorder may also avoid playdates and birthday parties. At home, they often “shadow” one parent constantly; as one clinician puts it, parents can begin to feel like “prisoners.” Vivid nightmares about family tragedy are also possible signs, as are tantrums and apparently defiant behavior when faced with separation. Younger children are mostly anxious at the time of separation, while older kids develop more anticipatory anxiety.

Risk Factors

Separation anxiety appears to be heritable. But it is often triggered by stress, trauma, or changes in environment—a move to a new home or school, a death or divorce in the family.

Diagnosis

For a diagnosis of separation anxiety disorder, a clinician looks for distress in being separated from—or anticipating separation from—parents or caregivers that's excessive for a child's age and prevents him from participating in age-appropriate activities. Symptoms include: worry about losing parents or other attachment figures though illness or death; unreasonable fear of an event that causes separation (getting lost, say, or being kidnapped); reluctance or refusal to leave home for school; undue fear of sleeping or being alone; persistent nightmares about separation; and physical symptoms (headaches, stomachaches) in conjunction with separation or anticipation of separation. 

 

To meet the criteria for separation anxiety disorder, the child must have the symptoms for at least 4 weeks.

Treatment

The first-line treatment for the majority of separation anxiety cases is psychotherapy; cognitive behavioral therapy in particular is used with great success on mild to moderate cases. In more severe cases and with kids who don’t respond well to CBT or other psychotherapeutic approaches, a course of medication may be indicated.

 

Psychotherapeutic: Treatment for separation anxiety disorder typically involves cognitive behavioral therapy, a treatment approach that helps children learn to understand and manage their fears. Exposure therapy, a specialized form of CBT, might also be used. Exposure therapy works by carefully exposing children to separation in small, controlled doses, helping to reduce their anxiety over time. Doctors might also use relaxation training and teach children to use coping statements.

 

Because parents can inadvertently reinforce anxiety when they are comforting anxious children, treatment frequently also involves parent training on how to respond to anxiety. Some doctors also recommend contingency management, which is a way to reinforce brave behavior by rewarding children for meeting their treatment goals. 

 

Pharmacological: When psychotherapy and behavioral interventions are not adequate to manage symptoms, medication may be prescribed to alleviate a child’s distress and facilitate therapy. A variety of medications have been shown to be effective in treating separation anxiety disorder; the first-line medication is one of the SSRIs, or selective serotonin reuptake inhibitor family. Typical anxiolytics—or anti-anxiety medications—like the benzodiazepines are also effective, though they can be habit forming.

Other disorders to look out for

Many kids with one anxiety disorder also have another, and they are more likely than average to be depressed, too. Both are true of separation anxiety. Usually the anxiety condition develops first, and is considered a risk factor for later depression. There is a strong correlation between separation anxiety in children and a diagnosis of  panic disorder later in life, and between separation and social anxiety disorders.

Frequently Asked Questions
When does separation anxiety become a disorder?
Anxiety is a normal part of growing up—between 6 months and a year of age, kids usually go through “stranger anxiety,” distress at the presence of people other than caregivers. And between a year and a half and three years, “separation anxiety” at being away from a parent for even a short period of time is normal. But when anxiety interferes with age-appropriate behavior, like going to school or sleeping in a room alone, it may be a disorder.
Will my child grow out of it?
In some cases, but not in most. And the longer the disorder goes untreated, the more resistant it becomes to treatment, particularly if a child has missed a lot of school or social activities because of her anxiety. And given that separation anxiety disorder is tied to other anxiety disorders and to depression, treating symptoms as early as possible is advisable.
Is it the result of a bad experience?
Many cases of separation anxiety disorder appear to be triggered by life changes or adverse events—particularly “late onset cases” that can come on after a move or a loss in the family, through death or divorce. But though change can trigger the onset of the disorder, it appears that a predisposition can be passed down from parents to children, either genetically or through other shared family experiences.
Is it my fault?
Social anxiety disorder is more common in kids with parents who themselves have or had the disorder. And by trying to help and accommodate an anxious child, caring parents can paradoxically make the disorder worse. It’s not bad parenting to empathize with your child, but since protective parenting could be enabling your child’s disorder, it’s important to seek treatment.
How long is treatment?
If a case is caught early, a child can respond rapidly to behavioral treatment, sometimes in a manner of days. And pharmacological interventions can produce results in as little as a week or two, though the prescribing physician will usually recommend continuing with the medication for at least 6 months. Generally, the duration of psychotherapeutic interventions via cognitive behavioral or desensitization therapy, among others, will vary based on the severity of the case—but experts council that it will be more effective and less onerous if treatment begins early and the family is engaged in the process.
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