Children look to their parents for security, guidance, comfort. Braving the world and experiencing things for themselves can be a very scary thing. Separation anxiety is defined as excessive worry or fear experienced by a child when they are separated from a primary caregiver. This is a completely normal situation for infants and toddlers as they begin to explore new boundaries and test their independence. Separation anxiety is considered a normal developmental event between the ages of 6 months and 30 months. It is often at its worst between 13 and 18 months. You may see a toddler playing freely and suddenly running back to a caregiver for reassurance. They are testing their level of comfort with the world.
Usually separation anxiety declines significantly between 3-5 years as children are able to rationalize the reason why they are separated from a caregiver and begin to trust that mom or dad is will really come back to them eventually. Occasionally though, this normal decline in anxiety doesn’t occur. Occasionally separations cause more and more distress and are accompanied by worry that the separation will be forever. There may also be headaches, stomachaches, school refusal and even nightmares about separation. When it causes this much distress beyond about 3 years of age, we would classify that as separation anxiety disorder (SAD).
SAD affects about 3-5% of children and adolescents. It may be slightly more common in girls than boys. In reality, many kids suffer from symptoms of separation anxiety disorder but are never diagnosed because the symptoms aren’t disruptive enough to seek treatment. It typically peaks between the ages of 7 and 9 and is often associated with a stressful life event. One of the key features of SAD as opposed to other anxiety disorders is that children with SAD typically are very content when they are with their primary caregiver. The anxiety is usually only present when they are away from their parent. This is different from generalized anxiety disorder, which is a type of anxiety that lasts all the time regardless of who is nearby. Kids, though, who are diagnosed with SAD are also more likely to have generalized anxiety, specific phobias/fears, ADHD, fear of social situations and even oppositional defiant disorder which can make diagnosis of SAD a little trickier.
There are a lot of theories about how SAD develops. Children with SAD are often more shy and introverted than children without SAD which could lead them to be more uncomfortable with new situations and environments to begin with. Sometimes they tend to cling more to their parents in uncomfortable situations. There may be a history of something bad actually happening to a parent or the child such as a car accident, medical problem, burglary, etc. That can trigger a fear that something will happen again when they are separated. There is also a theory that early in the child’s life the bond between the parent and child is stressed. For instance, if the child spends a lot of time away from his primary caregiver because of an illness, work, foster care, etc. then the usual period of testing the boundaries may be disrupted and lead to insecurity.
There is a hereditary component to SAD. Parents of children with separation anxiety are more likely to have depression, panic attacks and other symptoms of anxiety. So, while anxiety can be hereditary, it can also be something that kids pick up just by being around anxious parents. Different parenting styles may also predispose kids to SAD. For instance, if a parent is hesitant to let their child explore the world it may lead the child to think that the world is unsafe. It’s important for parent s and kids to develop a balance between testing the world and keeping each other protected and safe.
Treatment of SAD depends on the severity of the anxiety. If it is caught early and is not too disruptive to daily life, beginning with therapy can be very effective. One type of therapy called cognitive behavioral therapy (CBT) is heavily researched and most recommended. CBT is a type of talk therapy that is based on the theory that our thoughts affect our emotions and behaviors. For instance, if you’re thinking about a lot of negative things you are more likely to feel down or angry. Or, if you are thinking about all the things that can go wrong you will probably feel more nervous, anxious and scared. CBT is effect in SAD by helping the child break the cycle between worrying about what will happened when they are separated from their caregiver, feeling anxious about the separation and staying near their caregiver.
In true CBT, the key is completing the homework assignments that the therapist gives the family. Assignments usually involve exposing the child to planned separations and giving them techniques to reduce the anxiety during the separations. It’s important for the child to face the very situation that they are worried about and to re-learn that their parent will come back to them. This can be very hard for parents to do as well because of fear that they are causing more anxiety for their child. We would typically start with very short separations and increase the amount of time slowly until they no longer feel anxiety during separation. This particular type of CBT is called exposure therapy. With time, the child experiences less and less anxiety because the cycle is broken when mom and dad keep coming back to them. They slowly stop worrying about what will happen when mom or dad are gone because they do come back.
If kids are really anxious or cannot tolerate the exposure therapy even for short periods of time, adding medication is recommended. The class of medications known as the SSRIs, such as Prozac, Celexa, and Zoloft, are usually the first-line medications. These can be helpful in reducing the overall level of anxiety and improving mood. This particular class of medication does not work overnight and have to be taken daily. Usually some benefits are seen within 2-3 weeks but the full effects are not seen for 4-6 weeks typically. The choice to add medications is very individual and is important to discuss with your physician.
Kids with separation anxiety disorder generally do very well with appropriate treatment. The earlier treatment is sought, the more easily the cycle of worrying can be broken. Most children recovery quickly and do not require long term treatment for the separation anxiety.
