What is separation anxiety disorder?
In order to comprehend separation anxiety disorder, it is crucial to first acknowledge the typical challenge that infants and toddlers face when encountering strangers and when separating from their parents and caregivers. Infants exhibit stranger anxiety by crying when approached by someone unfamiliar to them. This natural phase of development is linked to the infant's process of recognizing their parents or other familiar caregivers from unfamiliar individuals. According to the American Academy of Paediatrics, stranger anxiety typically begins around 8 months of age and resolves by the time the child is 2 years old.
Separation anxiety as a normal life stage first develops at about 7 months of age, once a baby understands that his or her caregivers do not disappear when out of sight (object permanence). That leads to the baby developing a true attachment to those adults. Normal separation anxiety is most commonly at its strongest at 10-18 months of age and gradually subsides, usually by 3 years of age. 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.
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 whose parents response anxiously and dramatically to certain situations tend to be anxious children.
Separation anxiety disorder is a mental health disorder that typically starts during childhood and is characterised 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.
What are the symptoms and signs of separation anxiety disorder?
Symptoms of separation anxiety disorder may include:
• Recurrent, excessive distress when separation from home or major attachment figures occurs or is anticipated;
• Persistent or excessive worry about losing, or about possible harm befalling, major attachment figures;
• Persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped);
• Persistent reluctance or refusal to go to school or elsewhere because of fear of separation;
• Persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings;
• Persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home;
• Repeated nightmares involving a theme of separation;
• Repeated complaints of symptoms (such as headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated.
To qualify for the diagnosis of separation anxiety disorder, a minimum of three of the above symptoms must persist for at least a month and cause significant stress or problems with school, social relationships, or some other area of the sufferer's life. Also, the disorder is not considered to be present if symptoms only take place when the child is suffering from certain other mental-health problems that better explain the symptoms.
School refusal may be a symptom of separation anxiety disorder, but it can also occur as a symptom of other anxiety disorders and is not a diagnosis by itself. 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.
Social anxiety disorder, another type of anxiety disorder, differs from separation anxiety disorder in that it is characterised by severe fear of most, if not all, social situations, not just events that result in separating from primary caregivers. This illness affects about 1% of children and adolescents and up to 5% of adults.
Individuals with social anxiety disorder may be children, teenagers, or adults, and the anxiety may interfere with the person's ability to function. Children with this problem may have difficulty with a number of ordinary activities, such as playing with their peers, talking in class, or speaking to adults.
What are causes and risk factors for separation anxiety disorder?
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 tend to be more at risk for developing this disorder.
How is separation anxiety disorder diagnosed?
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 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 may 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.
What is the treatment for separation anxiety disorder?
Psychological therapy, 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 therapy alone, suffer from more severe symptoms, have other emotional problems in addition to separation disorder, treatment should consist of a combination of approaches. Psychotherapy, medication, and parent education are three interventions that have been found to be effective for the treatment of separation anxiety disorder, particularly in combination.
Behavioural modification therapy is an intervention that directly addresses the behavioural symptoms of separation anxiety disorder (e.g., tantrums, reassurance seeking, school refusal, coming into parent's room repeatedly). 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. For example, instead of withholding dessert from a preschooler who refuses to go into her room for bedtime, give hugs and praise for the child when she can go near her room at first, followed by being able to go in and stay for five minutes, increasing the length of time she needs to be in her room before being praised. Even if she needs significant parental support at first (for example, sitting in the room with her on the parent's lap, then next to her, then just outside the room after she becomes comfortable with each step), this approach allows the child to feel a sense of success at every step and build on it rather than experiencing a sense of failure, which tends to lower the child's likelihood of being able to overcome her anxiety. The implementation of behavioural therapy generally involves the practitioner providing parenting tips to the child's caregivers, regular meetings with the child, and may include guidance to teachers on how to help alleviate the child's anxiety.
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. Formal relaxation techniques may be considered more appropriate interventions for older children, adolescents, and adults, but even toddlers can be taught simple relaxation techniques, such as imitating their parents, taking deep breaths, or slowly counting to 10 as ways to calm themselves.
If psychotherapy is unsuccessful or if the children's symptoms are so severe that they are nearly incapacitating, medication is considered a viable option to be discussed with a paediatrician or psychiatrist. Selective serotonin reuptake inhibitors (SSRIs) such as fluvoxamine (Luvox) have been found to be an effective treatment for separation anxiety disorder.
SSRIs are medications that increase the amount of the neurochemical serotonin in the brain. These medications work by selectively inhibiting (blocking) serotonin re-uptake in the brain. This block occurs at the synapse, the place where brain cells (neurons) are connected to each other. Serotonin is one of the chemicals in the brain that carries messages across these connections (synapses) from one neurone to another.
The SSRIs work by keeping serotonin present in high concentrations in the synapses. These drugs do this by preventing the reuptake of serotonin back into the sending nerve cell. The reuptake of serotonin is responsible for turning off the production of new serotonin. Therefore, the serotonin message keeps on coming through. It is thought that this, in turn, helps activate cells that have been deactivated by anxiety, thereby relieving a child's anxiety symptoms.
SSRIs are generally well tolerated but side effects should be discussed with your child's doctor. All people are “biochemically” unique so the occurrence of side effects or the lack of a satisfactory result with one SSRI does not mean another medication in this group will not be beneficial. However, if someone in the patient's family had a positive response to a particular drug, that drug may be preferable to try first.
What happens if separation anxiety disorder is left untreated?
Separation anxiety disorder puts its sufferers at risk for depression and anxiety problems as adults. However, most children with separation anxiety do not exhibit symptoms in adolescence. Separation anxiety or another form of anxiety can reoccur after a period of stress after treatment. Further treatment should be sought if this occurs and a new coping plan created to build on previously learned techniques.
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