Separation Anxiety Disorder

Separation Anxiety

Most of us can remember a time during childhood where we had suddenly realised that we had become separated from our mother or father and could not find them (Mental Health Foundation of New Zealand (MHFNZ), 2002). Memories of that fear of being lost and alone, and the relief that is felt once reunited again stay with us long after the situation occurs. Once reunited though, we most likely worry about getting lost again so we made sure our parents were in close view until the incident faded away. Feeling anxious about being separated from parents is a normal reaction for children to experience. This is called separation anxiety and it is a protective mechanism which has a tendency to fade away as children get older.

Separation Anxiety Disorder

Some children however can experience continuous feelings of fear and extreme anxiety about the very thought of being separated from their parents (MHFNZ, 2002). These children have a tendency to constantly think about the possibility that they may be separated from their parents. In their minds, something terrible will happen to their parents if they are separated. They make sure their loved ones are in their view and follow them wherever they go even if it is only into the next room. If separation occurs, the child's 'fear thermometer' increases to a level of panic which can result in crying, pleading, struggles, sobbing and intense clinging. Children who display behaviours such as extreme clinging and anxiety may have separation anxiety disorder.

It is important to recognise however that it is completely normal for toddlers and school aged children to show a certain amount of anxiety over actual or threatened separation from parents or loved ones (Dabkowska, Araszkiewicz, Dabkowska, & Wilkosc, 2011). Separation anxiety is considered to be a disorder when it is unusually severe and continues beyond the typical age when children are expected to experience anxiety when separated from parents, particularly when they are in situations or environments that are not familiar to them. Separation anxiety disorder also interferes considerably with day to day activities a child would normally be doing.

Normal Anxiety or Separation Anxiety Disorder

In the early years of childhood, crying, tantrums, or clinginess are normal responses to separation (Robinson, Segal, & Smith, 2013). Separation anxiety can develop in a child’s first year of life, and may arise again or continue until a child is four years old however the strength and timing of separation anxiety can vary significantly from child to child. It is considered normal for a child of any age to show a small amount of worry over being apart from their parents. This worry can be eased by remaining patient and consistent, and by gradually but firmly setting limits.

Nevertheless, some children experience separation anxiety that fails to disappear, despite a parent’s best efforts (Robinson et al., 2013). These children experience severe separation anxiety intermittently or for long periods of time during high school or beyond. If separation anxiety is so extreme that it disrupts normal activities such as school and friendships, and continues for months rather than days, it may be a sign of separation anxiety disorder.

Anxiety in General

To understand separation anxiety disorder thoroughly, it is beneficial to have an understanding of anxiety in general (Boston Children’s Hospital, 2011). We are all born with a “fight or flight” response that is activated to help us escape danger and other threats. When people become worried, frightened or stressed, the part of the brain that is in control of the fight or flight response generates the nervous and the fearful sensation of anxiety. While everyone feels anxious at times, individuals with anxiety disorders deal with constant and excessive worrying that does not fade away like normal anxiety does. A young person with an anxiety disorder struggle to “just put their worries aside,” regardless of how hard they try. They feel considerably more anxious, and for a longer amount of time, than other children do in the same circumstances.

Signs and Symptoms of Separation Anxiety Disorder

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (APA, 2000), a handbook to assist mental health professionals with diagnosis, lists the following criteria for separation anxiety disorder.

Recurrent excessive distress upon separation. The child may think constantly about a possible separation long before an event occurs, or just at the time the separation is thought to happen (Pledge, 2013). The child can then be subjected to tremendous distress that shows up each time the child expects to be separated from their parents. The fears associated with separation generate more anxiety and the emotional response strengthens.

Persistent and excessive worry. The child may worry that they themselves or their parents may be subjected to some kind of harm, or they may worry about becoming lost or separated from the parent/s and never be reunited again (Pledge, 2013).

Repetitive nightmares. The child may experience recurrent nightmares which can involve being chased, harmed, or becoming separated from parents. Some of these fears are considered to be age-appropriate, however in separation anxiety disorder the strength of the fears become overwhelming to the child, which can reduce their ability to manage emotions or behaviours (Pledge, 2013). While dreams allow children to explore and understand daily life, those with separation anxiety disorder have a tendency to have nightmares that represent their irrational fears or excessive concern with disaster.

Complaints of physical symptoms. The child may pretend to be sick (headaches, stomachaches, etc.) to prevent separation, or on the other hand, actually experience nausea before separation occurs (Pledge, 2013). If this behaviour is supported, the child’s symptoms may become psychosomatic (physical symptoms with a psychological origin) which prevent the child from going to school or engaging in school activities. As a consequence, the separation anxiety can progress into a more serious state in which the child complains of chronic pain, and as a result, the child gets what they want (i.e., not attending school).

Persistent reluctance or refusal to engage in age-appropriate activities. The child may refuse to go to school because of their worries about being separated from the parent (Pledge, 2013). In addition, the child may be unwilling to be alone at home or at school without having another adult immediately available. The child may also refuse to go to sleep without an adult nearby. The disorder interferes with a child’s daily routine and may have a considerable impact on the child’s ability to complete

previously mastered tasks. It may seem that the child has reverted back to behaviours from a younger age. The strength of a child’s emotions has a significant impact on their ability to convey their feelings in ways other than through behaviours, such as tantrums, hitting, or clinging. One behaviour typically seen in separation anxiety disorder is crying, which can be quite intense and difficult for the child to control.

Extra features of Separation Anxiety Disorder include:

Enmeshment or unusual interest in parents' schedules. The child wants to be informed of the parent’s daily schedule, which essentially reduces the anxiety experienced by the child (Pledge, 2013).

Quick resolution of symptoms (upon meeting child's demands). Parents may find it difficult to accept the reality of the disorder because the symptoms have a tendency to rapidly disappear when the threat of separation is avoided (Pledge, 2013). This component can make the people in the child’s life feel manipulated.

Associated Features with Separation Anxiety Disorder

In general, children who develop separation anxiety disorder come from families that are closely united (APA, 2000). When they find themselves separated from parents or families, they may demonstrate behaviours such as social withdrawal, apathy, sadness, or difficulty concentrating at school. Subject to a child’s age, they may develop a fear of animals, monsters, the dark, robbers, kidnappers, car accidents, flying on a plane, and other situations that can be seen as a threat to the integrity of the family or themselves. Children may also have worries about dying or death and also refuse to attend school which can have a significant impact on their learning and contribute to social avoidance. They may also believe that they are not loved or cared about and may wish to die. When a child becomes particularly distressed at the thought of being separated from their parents, they may express their anger or even become aggressive with the person forcing the separation. At night while alone, children have a tendency to report unusual perceptual experiences such as scary creatures trying to grab them and feeling someone staring at them. Children who develop separation anxiety disorder are usually seen demanding, intrusive, and require a lot of attention. This demanding nature can lead to parental frustration, which can result in resentment towards the child and conflict in the family. Sometimes, children with separation anxiety disorder are seen to be responsible, obedient and eager to please. They may also have somatic complaints that result in continuous doctor appointments and medical testing. In addition, these children often present with a depressed mood which can become more persistent over time. This can sometimes result in an additional diagnosis of dysthymic disorder or major depressive disorder. The disorder may also follow the development of panic disorder with agoraphobia and be combined with several other anxiety disorders.

Causes of Separation Anxiety Disorder

Genetic influence. Research indicates that there is a genetic link between separation anxiety disorders in children and a history of panic disorder, anxiety, or depression in their parents (Dabkowska et al., 2011). In addition, babies who display anxious temperaments have a tendency to develop anxiety disorders later in life.

Developmental considerations. It is important to consider that children grow at different rates (for example, girls mature faster than boys) (Pledge, 2013). In addition, the rate of development in children can vary across several areas of functioning (for example, a child can be highly intelligent for their age but in contrast lack the skills for social and emotional functioning expected for their stage of development). When a child’s development in the intellectual, social, emotional, or physical areas are slow, it can bring on anxiety which makes separation more problematic.

Parent/child attachment. The quality of attachment between a child and their parents have also been recognised as a factor in the development of separation anxiety disorder (Dabkowska et al., 2011). If the child detects emotional distance from parents, they may display behaviours that attempt to pull the parent in closer. These disruptive behaviours can also attract the attention and care of other people.

Cognitive factors. Children constantly worry about what frightens them (for example, losing their parents or a parent getting injured) (Pledge, 2013). These thoughts generally repeat themselves within the child's mind until their emotions are outside their control. The child may have difficulties thinking about something that is not related to their fears and as a result further escalate their anxiety and promotes irrational behaviours.

Behavioural factors. The crying and clinging behaviours that a child shows may be a coping mechanism to handle their anxious feelings that are related to specific people, environments, or situations, such as going to school (Pledge, 2013). Children engage in these behaviours in order to distract the attention from their negative emotional state, while at the same time nurturing the worry and fear into a bigger part of the child's daily life. The behavioural aspect for young people can develop as a way of expressing the anxiety they are experiencing. The behaviour may also come across as manipulative as the symptoms the child experiences suddenly disappear once the threat of separation passes.

Stress factors and influence. Symptoms of separation anxiety disorder may become worse as a result of a change in routine, becoming unwell, inadequate rest, moving to a new home, going to a new school or change in family structure (such as death, divorce, parent illness, birth of a sibling) (Dabkowska et al., 2011) . The child's symptoms may also be influenced by changes in a parents' response to the child in relation to discipline, availability, or daily routine. Regardless of the changes being positive or negative, it may be unpleasant for the child and as a result trigger an anxious response.

Prevalence of Separation Anxiety Disorder

The prevalence of separation anxiety disorder is in general cited between 3.5% and 5.4% (Black, 1995). However, considerably more children experience the symptoms of separation anxiety disorder but do not warrant a diagnosis. The prevalence of separation anxiety disorder also generally decreases from childhood to adolescence (APA, 2000). In relation to differences of prevalence between genders, several studies have found that girls are diagnosed more with separation anxiety disorder than boys (Last, Francis, Hersen, Kazdin, & Strauss, 1987), although researchers generally agree that there are no significant gender differences (Last, Perrin, Hersen, & Kazkin, 1992).

The average age of onset for separation anxiety disorder is in middle childhood, generally between 7 and 9 years of age (Hanna, Fischer, & Fluent, 2006). Although symptoms may

begin to arise as early as preschool age, by definition, it can occur any time before age 18 years. In one study with a large sample, children with a diagnosis of separation anxiety disorder had the earliest age at onset averaging at 7.5 years and the youngest age at intake averaging at 10.3 years compared with children who were diagnosed with other anxiety disorders. Although separation anxiety disorder is traditionally considered to be unique to childhood, separation from attachment figures can continue or even arise during adulthood.

Onset and Course of Separation Anxiety Disorder

The onset of separation anxiety disorder is described as either acute or insidious (Black, 1995). Acute onset usually develops after a significant stressful event in the child’s environment such as starting school, moving to a new home, or other significant events that disrupt the child’s routine such as changes in the family setting (e.g., divorce). The course of separation anxiety disorder has been found to vary considerably. Some children, mainly those who displayed an acute onset, completely recovered from the disorder with no lasting consequences. It has been found that for most children with separation anxiety disorder, symptoms improve significantly while still in early childhood (Kearney, Sims, Pursell, & Tillotson, 2003). Other children however may experience a longer lasting and continual course. Children who develop the disorder with a later onset and who they themselves and other members of their family had other psychiatric disorders have a higher risk for developing anxiety disorders as an adult. In particular, when separation anxiety disorder is long lasting, there is a higher risk of developing the adult equivalent of the disorder (Silove, Manicavasagar, & Drobny, 2002), or panic disorder (Casat, 1988). It is also debated whether separation anxiety disorder is actually an early indication for the development of panic disorder, instead of merely a risk factor.

Comorbidity of Separation Anxiety Disorder

A significant number of studies have found high rates of psychiatric comorbidity in children with anxiety disorders (Chase & Eyberg, 2008; Franco, Saavedra, & Silverman, 2006; Kendall, Brady, & Verduin, 2001; Shear, Jin, Ruscio, Walters, & Kessler, 2006). It has also been found that children with anxiety seldom present for treatment for only one disorder. In relation to children with separation anxiety disorder, 79% had at least one comorbid disorder, with the majority having other anxiety disorders (Kendall et al., 2001).

A high amount of comorbidity has been found between separation anxiety disorder and panic disorder, particularly at the symptom level. For example, it has been found that comorbid separation anxiety is as high as 73% in young people with panic attacks (Masi, Favilla, Mucci, & Millepiedi, 2000). In addition, considering generalised anxiety disorder and obsessive compulsive disorder are both associated with worry and somatic complaints, it is not a huge surprise that people with these disorders also present with separation anxiety disorder. Generalised anxiety disorder has been found to present with separation anxiety disorder approximately one-third of the time (Kendall et al., 2001). Similarly, obsessive compulsive disorder presents with separation anxiety disorder at approximately 24-34% of the time (Geller, Biederman, Griffin, Jones, & Lefkowitz, 1996; Valleni-Basile et al., 1994). However, the comorbidity of obsessive compulsive disorder and separation anxiety disorder is related to an earlier onset of panic disorder (Goldwin, Lipsitz, Chapman, Fyer, & Manuzza, 2001).

The connection between anxiety and depression in children is well established (Brady & Kendall, 1992; Suveg, Hoffman, Zeman, & Thomassin, 2009). Therefore, there is no surprise

that children and adolescents commonly present with both separation anxiety and depression. It has been found that as many as one-third of children who have separation anxiety disorder also develop a depressive disorder (Shear et al., 2006). Depression usually develops for these children as a result of separation anxiety disorder, especially when it becomes unbearable and/or interferes with at least two areas of functioning (e.g., school, peers, or family) (Eisen & Schaefer, 2005).

Disruptive behaviour disorders also frequently occur with separation anxiety disorder (Hammerness et al., 2008). It was found that attention-deficit hyperactivity disorder (21.7%), oppositional-defiant disorder (19.6%), and conduct disorder (21.4%) were the most frequently occurring externalising disorders that presented with separation anxiety disorder (Shear et al., 2006).

Differential Diagnosis for Separation Anxiety Disorder

Separation anxiety can be related to several disorders such as pervasive developmental disorders, schizophrenia, or other psychotic disorders (APA, 2000). If a person displays symptoms of separation anxiety disorder exclusively during the development of one of these disorders, separation anxiety disorder is not diagnosed separately. Separation anxiety disorder presents differently from generalized anxiety disorder as the anxiety revolves around fears of separation from home and parents. For young people with separation anxiety disorder, the threat of a separation can result in severe anxiety or panic attacks. When compared to panic disorder, the main worries revolve around being separated from attachment figures or from home instead of being incapacitated by a panic attack. Sometimes when children refuse to attend school, particularly during adolescence, it can be due to social phobia or mood disorders as oppose to separation anxiety. Children who have separation anxiety disorder may be very resistant when in the position of being forced to separate from their parents or loved ones. Therefore a diagnosis of oppositional defiant disorder should be given only if the oppositional behaviour is expressed during situations that are not associated with separation or when the child predicts separation. Similarly, when a child with separation anxiety disorder predicts a separation or are in the process of being separated from their parents, they may develop feelings of depression. Therefore a diagnosis of depressive disorder should be given only if the depression arises at other times.

Treatment for Separation Anxiety Disorder

Cognitive-behavioural therapy

Cognitive-behavioural therapy is a popular and successful treatment approach that is intended to change a person’s thoughts, beliefs, and images in order to change certain behaviour (Pledge, 2013). The main goal with treating a child with separation anxiety disorder is to assist them with labeling their fears and recognising their irrational beliefs and assumptions that underlie their fears. This technique helps children confront and correct their false beliefs and therefore reduce their anxiety about separation.

Imagery

Imagery is a specific technique that requires a person to use their imagination to see themselves succeeding in a stressful and anxious situation (Pledge, 2013). For example, before a child with separation anxiety disorder goes to school, they could imagine what

would happen when they are separated from their parent. Instead of crying, the child imagines themselves saying goodbye to their parent calmly. Using positive images can help reduce some of the child's worries and fears before they are confronted with the separation.

Modeling

Modeling is a vicarious learning principle that is used with children who have separation anxiety disorder in order to demonstrate suitable responses and coping behaviours when separated from parents (Farris & Jouriles, 1993; Gosch, Flannery-Schroeder, Mauro, & Compton, 2006). It can be used in different ways such as live modeling, video modeling, or participant modeling (Farris & Jouriles, 1993). Live modeling involves the child to observe another child or person participating in a desired behaviour (e.g., calmly sleeping in one’s bed alone). Video modeling requires the child to observe another child or person through a video participating in a desired behaviour. Participant modeling involves the child observe another child or person involve themselves in the desired behaviour while the child also engages in the same behavour. For children who develop significant distress when leaving their parent to go to school, this process may require the child to watch their brothers, sisters or relatives get ready for school, say goodbye to their parents and walk to school and into their classrooms calmly, while the child with separation anxiety disorder also partakes in the same behaviours.

Systematic desensitization

Systematic desensitization is a behaviour modification technique that involves a person to gradually become exposed to an anxiety-provoking or fearful object or situation while at the same time learn how to relax (Pledge, 2013). A child with separation anxiety disorder may be shown how to use relaxation techniques in order to manage their anxiety, and, therefore can attend school for longer durations without a parent present.

Parent-child interaction therapy

Research on intervention strategies for children under 7 years of age with separation anxiety disorder has been limited (Bernstein & Victor, 2010). However, parent-child interaction therapy has been supported by research as a viable treatment option for children with disruptive behaviour disorders and has been modified to suit young children with separation anxiety disorder (Pincus, Eyberg, & Choate, 2005). Parent-child interaction therapy helps parents to control the behavioural problems with their child and encourages a more positive relationship between the parent and child and as a result improves the connection and warmth between them. It is anticipated that this strategy will assist the child to separate from the parent by strengthening the child’s sense of security. Parent-child interaction therapy also involves the teaching of parenting skills that can also promote the reduction of a child’s anxiety (e.g., attention from the parent toward child, differential reinforcement, behavioural modification, giving strong directions).

Coping Cat Model

Coping Cat Model is treatment program developed by Philip Kendall and has been found to be effective in approximately two thirds of cases (Podell, Martin, & Kendall, 2008). This program has had successful outcomes with some comorbid conditions as well as separation anxiety disorder. Coping Cat consists of many layers such as education as well as cognitive, affective, sociological, parent and family, and behavioural elements. The therapist gives the

child psychoeducation so they can become aware of the difference between normal and excessive anxiety and self-talk that is associated with anxiety. Children are also taught relaxation techniques to decrease anxiety and skills to improve their behaviour. A major element of this technique is the graded use of exposure tasks so the child can be exposed to real situations which bring on arousal and then learn how to manage their anxiety effectively. The treatment initially begins with an educational phase and then moves on to an exposure phase. Therapists teach children that a small amount of anxiety is acceptable. Children also learn to recognise the cognitive processes that are involved and implement coping skills so they can face their fears and reduce their need to avoid the situation. By initially learning this process in session and then rehearsing outside of session, the child can feel confident that the coping skills they are using are effective.

Behaviour modification

A child may be able to conquer their fears of separation by a way of reorganising certain reinforcements in their environment, which can help the child to take part in activities without the parent being around (Farris & Jouriles, 1993). It is recommended though to apply gradual, step-by-step procedures in order to modify the child’s behaviours successfully. Teachers and other people looking after the child are taught to stop inadvertently supporting the separation anxiety behaviours, such as tantrums with attention that is positive and therefore eliminating the situation they are scared of. As an alternative, caregivers are trained to use positive reinforcement strategies with the child, such as attention and rewards, for behaving in the desired way while not paying any attention to the undesired behaviours. This intervention is also known as contingency management (Barrett, Dadds, & Rapee, 1996).

Pharmacotherapy

Prescribed medication should only be used for the more non-compliant and difficult cases, or with people who have such extreme anxiety that it significantly interferes with therapy based exposure procedures (Rhoads & Donnelly, 2013). Although at present, there is no approved medication for the treatment of separation anxiety disorder, Selective Serotonin Reuptake Inhibitor’s which are also known as SSRI’s are considered to be the first line of drug therapy. Additional medications such as clonazepam which provides short term relief for anxiety may be used while waiting for the SSRI to work at its full capacity, although this strategy is only an appropriate option for older children. Tricyclic antidepressants (e.g., clomipramine, imipramine) have been found to have positive results in the past, although not prescribed as much anymore because of the negative side effects and potential for cardiac toxicity. It is important to recognise however that Cognitive Behavioural Therapy (CBT) is expected to be the most effective and enduring treatment for separation anxiety disorder.

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