What is Separation Anxiety Disorder?
Anxiety is a tense emotional state often accompanied by uneasiness, persistently worrying about what the future holds. Fear, a reaction to both envisioned and real risks, often coincides with anxiety. This widely felt experience can lead to constant worry, restlessness, and physical signs such as a racing heartbeat. While it’s a normal reaction to threats, it becomes a problem when it overpowers a person’s life, causing ongoing distress, a drop in life enjoyment, and hindrance in daily tasks.
Anxiety disorders are the most frequent mental health conditions in children but often go unrecognized. If left untreated, anxiety disorders in children can considerably degrade their quality of life and may promote other mental health issues. It also hampers their social, emotional, and educational growth significantly. The impact of anxiety on adults is also considerable, as it often results in a lower quality of life and can affect day-to-day activities.
One common anxiety disorder in children is Separation Anxiety Disorder (SAD). Children suffering from SAD experience significant distress unexpectedly separated from home or from someone they’re closely attached to. In essence, SAD magnifies ordinary anxiety to unreasonable proportions, causing the child to excessively worry or even fear to be separated from their attachment figure or home.
Separation anxiety is a normal phase of childhood development, but the disorder comes into play when this anxiety is too intense, happens at the wrong age, or in an unfitting situation. Initially, SAD was diagnosed only in children and teenagers. However, the diagnosis has now been extended to adults diagnosed with SAD later in life. One notable difference here is that children usually get anxious when separated from adult carers like parents, whereas adults with SAD get anxious over being away from children, spouses, or partners.
Typically, separation anxiety shows up between 6 to 12 months of age. This common form of separation anxiety is usually noticeable until the child is around 3 years old and generally decreases after that. As the child grows older, develops better cognitive abilities, and learns that people they’re attached to will return, the anxiety naturally fades away.
If separation anxiety lasts longer than expected or is more severe, or if it develops in older children, teens, or adults, it can indicate SAD. This disorder can greatly impact various aspects of life, such as performance at school or work, social interactions, and close relationships. It also serves as a stepping stone to more detrimental mental and physical health problems, like excessive worrying, sleep issues, social anxiety, poor school performance and physical symptoms.
What Causes Separation Anxiety Disorder?
Mental health conditions, such as anxiety disorders, can be caused by a mix of biological, psychological, and social factors. While psychological factors play a significant role, there are also biological aspects to these disorders. Research has shown that anxiety disorders often run in families, implying a genetic link to anxiety. Identical twins, who share the same genetic material, are more likely to both have anxiety compared to non-identical twins. Changes to our genes, particularly those involved in handling stress, can also contribute to anxiety.
Behavioural scientists have shed light on how our mind contributes to anxiety, particularly separation anxiety. People with anxiety disorders have a stronger reaction to fear and are less likely to be reassured by safety cues.
One theory, called the attachment theory, explains how children need a caregiver around for normal emotional and social development. There are four attachment styles: secure, anxious-avoidant, disorganized, and anxious-ambivalent. The last one, anxious-ambivalent, is most commonly seen in those with separation anxiety disorder (SAD). The main symptom is feeling anxious when the caregiver is not around and not feeling entirely relieved even when the caregiver is present.
From an evolutionary point of view, separation anxiety might have helped our infant ancestors survive. It’s a normal part of human development, usually starting before one year of age, peaking when the child is nine to eighteen months old, and typically fades by 2.5 years. However, if this normal separation anxiety gets reinforced over time, especially when a child starts school, it can develop into SAD.
Parenting behaviours can also contribute to anxiety in children. Children can pick up anxiety from their parents through learning, observing and copying their anxious behaviours. Parenting styles that are overly protective, critical, responsive to child’s anxiety or accommodating of a child’s anxiety behaviour can contribute to the child developing anxiety. Kids with parents who have depression or anxiety disorders have a higher chance of developing these disorders themselves.
Risk Factors and Frequency for Separation Anxiety Disorder
Anxiety disorders, including separation anxiety disorder (SAD), are quite common in children. They can affect anywhere from 5 to 25% of kids worldwide. SAD is the most common type, making up half of the cases of anxiety-related treatment. Around 4% of kids suffer from SAD, and this number goes up to 7.6% in clinical cases. About 4.1% of children have a severe level of separation anxiety, and if they don’t get treatment, a third of these cases can continue into adulthood.
- The average age at which children start to show signs of SAD is around 6 years.
- In a study conducted in the United States, SAD had the highest lifetime occurrence rate, at 6.7%, among all anxiety disorders, excluding specific and social phobias.
- The lifetime prevalence of SAD in adults is 6.6%, with about 77.5% of these cases beginning in adulthood.
Signs and Symptoms of Separation Anxiety Disorder
Separation anxiety disorder (SAD) in a child is often identified by a parent or caregiver who notices that their child struggles when separated from them, impacting day-to-day lives. This anxiety might be most visible in areas like school or home life. A common sign is that the child’s school performance becomes affected. Even if the parent isn’t primarily concerned about the separation anxiety, it’s crucial to scrutinize the child’s progress at school. Questions to consider are where the anxiety happens most, the age it started, and whether it worsens in certain situations. Additionally, it’s important to observe whether the child expresses extreme fears related to separation, such as getting kidnapped or hurt when the caregiver isn’t around.
Doctors can get a clearer diagnosis by understanding the child’s development and social history. Knowing about the child’s living situation and relationship with their caregiver can offer details of their earlier life and caregiver stability. There might also be signs of trauma, like sexual or physical abuse, that should be screened for. Checking for any previous mental health issues is also necessary, as anxiety disorders often occur with other conditions in children. SAD could be inherited if a parent or caregiver has an anxiety disorder, and it’s worth checking the development stage of the child, looking into their medical history and, when suitable, talking to the child individually.
For adults, understanding who they have difficulty being apart from is an essential first step. If they struggle to separate from a romantic partner, examining their dating history can be insightful. However, when exploring the patient’s trauma history, care should be taken as talking about any physical or sexual abuse could be challenging. With the patient’s consent, collecting additional information from the person that the patient has difficulty separating from can offer more information about the severity of the symptoms.
There are several areas to consider with SAD while carrying out a mental status examination. These include changes in behavior when separated from the caregiver, the speech used when talking about separation, feelings around the caregiver, thought content around catastrophic events, impulse control, and insight into their behaviors. Children with SAD generally lack insight, though adults may realize their behaviors are not helpful.
School is usually the first place where SAD is discovered in children. Complaints such as refusal to enter the school building, physically clinging to a parent, screaming when trying to be separated, and expressing symptoms like a headache could indicate SAD. Of children with SAD, around 75% refuse to go to school. SAD can also appear at home. Symptoms such as being afraid to be in a room alone, refusing to sleep alone, consistently staying by the caregiver’s side, and severe anxiety when separated from the caregiver are common. This can put a lot of pressure on the caregiver who might feel overwhelmed by the extreme demand for attention and loss of privacy.
Another typical symptom of SAD is worrying about harm coming to the caregiver when separated and having nightmares. The child may also worry about getting lost, being kidnapped, or having an accident if separated from the caregiver. In more extreme cases, children might become aggressive toward the person who is separating them from their caregiver, while adults may resort to constant communication with their attached figure. The person with SAD can seem demanding, causing frustration to family members or caregivers, thus perpetuating the disorder.
Testing for Separation Anxiety Disorder
If someone is suspected of having separation anxiety disorder (SAD), it’s crucial that they are referred for a psychiatric evaluation, preferably by a child and adolescent psychiatrist if possible. The first steps in this process are to build a trusted relationship with the patient, gather their background and history in detail from the patient and related caregiver(s), and carry out a mental status examination. To make a formal diagnosis, the healthcare provider can refer to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
To diagnose SAD according to the DSM-5, a person must experience significantly higher bouts of anxiety than is normal for their development stage during separations from persons they are attached to. This is identified by at least three particular signs, including excessive distress associated with real or anticipated separation, constant worry about a potential bad event occurring to their attachment figures, fear of being alone, nightmares about separation, and physical symptoms when facing separation. These symptoms must have persisted for at least four weeks in children and adolescents and generally six months in adults. The symptoms must also cause significant difficulty in important aspects of life, such as school or work, and they must not be better explained by another mental health condition.
There are numerous screening tools available to help evaluate potential anxiety disorders in children. These can be helpful if it’s tricky to get comprehensive diagnostic criteria from an interview. An example of a commonly used tool is the “Screen for Child Anxiety-Related Emotional Disorders” (SCARED) screener, which has shown excellent reliability and is often used globally.
Other tools specific to diagnosing SAD include the “Separation Anxiety Avoidance Inventory” (SAAI) and “Children’s Separation Anxiety Scale” (CSAS). While SAAI focuses exclusively on avoidance behaviors, it does not consider subjective aspects of worry and distress, which are fundamental to SAD. The CSAS covers four key factors of separation anxiety, including worry and distress related to separation, opposition to separation, and calmness at separation.
There is also the “Youth Anxiety Measure” (YAM), a newly developed questionnaire designed to identify anxiety disorder symptoms according to the DSM-5 in children and adolescents. Further validation is still needed for the YAM in a variety of populations. The “Anxiety Disorder Interview Schedule” (ADIS) is considered the gold standard for diagnosing anxiety disorders and covers all the anxiety-related disorders outlined in the DSM-5. It rates each diagnosis in terms of severity and the impact on daily functioning.
Further, the “Pediatric Anxiety Rating Scale” (PARS) is another clinical rating scale that measures the severity of anxiety based on frequency of distress symptoms, avoidance behaviors and interference in daily functioning. PARS has been validated in different populations and is widely used in clinical and research contexts, globally.
Treatment Options for Separation Anxiety Disorder
The appropriate way to handle Separation Anxiety Disorder (SAD) often depends on how severe the symptoms are. If the symptoms are mild, providing education about the condition to the patient and their parents, offering support and encouragement, and ensuring that the patient maintains a regular routine for eating, sleeping, and exercise could be enough to help them get back to their normal activities. It’s important to regularly check on the patient’s anxiety symptoms using validated screening tools to keep track of any changes.
If treatment is necessary, cognitive behavioral therapy (CBT) is often the first choice. Though selective serotonin reuptake inhibitors (SSRIs) are commonly used to manage anxiety disorders, there aren’t any medications approved by the FDA specifically for SAD.
CBT is the preferred treatment for SAD because it is effective and has a low risk of side effects. CBT helps patients by providing education about their condition, helping them change negative thought patterns, and gradually exposing them to situations that make them anxious. Effective CBT usually requires 10 to 15 outpatient sessions that last for about an hour to an hour and a half each, along with practicing new skills at home. The length of treatment can vary depending on how severe the symptoms are and if there are additional factors to consider. However, about 44% of children treated with CBT for anxiety disorders do not improve.
Using exposure therapy alongside CBT may improve treatment response. In exposure therapy, patients are gradually exposed to situations that cause them anxiety, with the aim of reducing their fear over time. This therapy’s effectiveness can be measured using electrodermal activity (EDA), which is a reliable indicator of emotional and physical arousal. The more distressed a patient is, the higher their EDA will be. High levels of arousal can predict a poorer response to brief CBT.
Coming to medication, even though there have been improvements in SAD with medication, there aren’t any medications specifically approved by the FDA for SAD and quality studies are lacking. Some studies suggest CBT and SSRIs are equally effective for children with anxiety disorders, while others report that CBT is superior. More recent data suggests that using CBT and SSRIs together is more effective than either treatment alone. Interestingly, patients who were given a placebo had a 23% response rate.
A study from 2008 reported that combining CBT and SSRI therapy was superior, due to the combined effects of the two therapies. The study, which included children with moderate to severe anxiety, found that CBT and the SSRI sertraline, either alone or together, were effective for treating childhood anxiety disorders, including SAD. However, when used together, they were more effective than either one alone.
In a recent review evaluating the effectiveness and safety of CBT and various medications for childhood anxiety disorders, it was reported that SSRIs and another class of medication called serotonin and norepinephrine reuptake inhibitors (SNRIs) improved anxiety symptoms when compared to a placebo. The effectiveness of benzodiazepines and a class of drugs called tricyclic antidepressants (TCAs) was not well-supported by the available evidence, and they’re not recommended for treating childhood anxiety disorders.
What else can Separation Anxiety Disorder be?
To correctly diagnose anxiety-inducing stressors, it is critical to identify what specifically is causing the anxious feelings. For individuals dealing with Separation Anxiety Disorder (SAD), typically the distress comes from being separated from a person they feel close to. This anxiety can appear similar to other types of anxiety disorders – like generalized anxiety disorder, social anxiety disorder, specific fears, and panic disorders. Also, it’s not unusual for patients to have multiple types of anxiety disorders at the same time.
The tool called SCARED is recommended to help diagnose anxiety disorders in children accurately. It works by distinguishing one type of anxiety disorder from others. For adults dealing with SAD, their symptoms might be similar to elements of borderline personality disorder, such as fears of being abandoned, always being uneasy, and constantly worrying about separation.
What to expect with Separation Anxiety Disorder
In a study of 242 participants with an average age of 10 years, it was found that 56% showed increased anxiety symptoms after one year, and 32% still showed signs of anxiety after three years. Furthermore, 8% of the subjects in the study had fluctuating symptoms of anxiety.
Research generally indicates that if left untreated, anxiety disorders tend to remain constant and don’t get better over time. However, with treatment, it’s believed that anxiety disorders in children usually improve over time. But, long-term research supporting this optimism is scarce.
Interestingly, a study that traced adolescents and young adults who had anxiety disorders in their childhood found that after four years, only about 22% of them had overcome their anxiety disorders, almost half of them had a relapse, while around 30% still had significant symptoms of anxiety. The study found that the type of treatment used (medication, cognitive behavioural therapy, a combination of both, or a placebo) did not make a difference in the chances of overcoming the disorder.
A 2013 review of studies found that children diagnosed with separation anxiety disorder (SAD) are at a higher risk of developing panic disorder and other anxiety disorders when they reach adulthood. However, this review did not find an association between childhood SAD and major depression or substance abuse disorders in adulthood. This is different from other studies which have suggested a link between anxiety disorders in childhood and depression and substance abuse disorders in adulthood, but these studies were not exclusively studying separation anxiety.
Possible Complications When Diagnosed with Separation Anxiety Disorder
Anxiety disorders in children can lead to school absences and lower educational attainment into young adulthood. This not only impacts the child’s life, but also results in economic costs due to lost productivity from caregivers and treatment expenses.
A recent study found that children with anxiety disorders often have issues with their working memory, understanding language, and writing. These challenges appeared more frequently and were more severe in children diagnosed with separation anxiety disorder (SAD) and children with multiple anxiety-related disorders.
The study showed that children with more severe anxiety had worse performance in several areas:
- Working memory
- Inferential processing
- Reading and writing
- Language understanding
These findings suggest that memory and language deficits are common in children with anxiety disorders. And, the more severe or numerous the diagnoses, the lower the child’s performance tends to be in memory and language skills.
Further studies have suggested a connection between separation anxiety disorder in childhood and personality disorders in adulthood. Notably, adults with a history of severe separation anxiety were more likely to have Cluster C personality disorders. Fear of being alone, a symptom common to both conditions, is also common in individuals with borderline personality disorder.
Anxiety disorders also heighten the risk of suicidal thoughts or actions. This risk remains even when taking into account other mental health disorders and life stress. Estimates suggest a 7 to 10% population risk of suicidality in adolescents with anxiety disorders.
Preventing Separation Anxiety Disorder
Educating parents is very important if we want to successfully treat children diagnosed with Social Anxiety Disorder (SAD). By learning how to positively reinforce and reward behaviors that lower anxiety, parents can help their kids avoid anxiety-driven behaviors. Addressing any anxiety or mental health issues the parents themselves might have can also help to enhance their child’s mental well-being.
Parents and caregivers also need to understand the overall process of treating SAD. This includes specifics such as how long the treatment will take, when they can expect to start seeing positive effects, and any potential side effects from medications. Parents should also be deeply involved with Cognitive Behavioral Therapy (CBT) and understand how to use both positive and negative reinforcements, so they can help improve their child’s behavior at home.
While SAD can’t be entirely prevented, early detection can really make a big difference in managing the condition. To help with this, the United States Preventive Services Task Force recommends that children and teenagers between ages 8 and 18 be routinely screened for anxiety disorders. They can use established screening tools such as SCARED. However, for children younger than 7, there isn’t enough evidence to argue for or against this type of screening for anxiety disorders.
