Separation anxiety disorder

Separation anxiety disorder—sometimes referred to inaccurately as “school phobia”—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. Perhaps 4% of children and adolescents have the disorder, which is very treatable with both behavioral and pharmacological therapies, particularly when it is caught early. 

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. 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 sufferers are mostly anxious at the time of separation, while older kids develop more anticipatory anxiety.

Researchers are unsure about the root causes of separation anxiety disorder, but it appears to have a genetic component. Parents who have had the disorder are more likely to have kids be diagnosed with it. Experts believe that stress, trauma, and changes in environment—a move to a new home or school, a death or divorce in the family—can contribute to the onset of separation anxiety disorder in older children. The disorder appears to stem from a problem in how the brain perceives danger and responds to it.

For a diagnosis of separation anxiety disorder, a clinician looks for severe anxiety about separation from parents or caregivers that causes significant distress and/or interferes with age-appropriate activities for an extended period. Other symptoms include: unreasonable fear of separation by accident or design (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. 

The first-line treatment for the majority of separation anxiety cases is behavioral 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: One technique used to manage separation anxiety goes by the moniker “contingency management,” which involves a “contract” and rewards. When the affected child performs the agreed upon behavior—not crying when dropped off at school, waiting a set period of time to call an attachment figure—she receives points towards a reward; this is a classic example of positive reinforcement, and has been shown to have a great effect on anxiety of all sorts. Progress can be slow, and patience is necessary. A therapist may also use exposure therapy: introducing a child in a controlled way to the stress of separation to gradually reduce and master the anxiety response.

 

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.

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.

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.