separation anxiety disorder essay

Separation Anxiety Disorder (SAD) Essay

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Strategies for the Different Stages of Development

Post operational care a child requires after abdominal/bowel surgery, assessments for a postop pediatric patient, pain scales used in pediatrics.

Separation anxiety disorder (SAD) is an anxiety condition in which a person has extreme anxiety when they are separated from their home and/or from persons with whom they have a deep emotional bond. SAD is defined by the American Psychiatric Association (APA) as an overabundance of dread and anguish when confronted with circumstances that demand separation from home and/or from a specific authority figure (American Psychiatric Association, n.d.). It is most frequent in infants and toddlers, but it can also affect older children, teenagers, and adults. Separation anxiety is a normal element of childhood development.

At such a young age it is crucial to establish rules of behavior to make a child accustomed to separating from their parents. A good strategy is to create specific good-bye rituals, which has to be quick. Otherwise a toddler will start thinking it’s a game and would not want to separate. Taking longer time for goodbyes will make the transition process take longer and as a result anxiety will increase as well. However, if established properly, a goodbye tradition will prepare the child that it is time to say goodbye and accustom them to being without parents at this age.

Consistency is particularly essential at this age. Whenever possible, try to conduct the same drop-off with the same ritual at the same time each day to prevent unexpected elements. A routine can help to ease the pain and enable a child to develop trust in both their independence and parents. Parents must also emphasize the need of “positive goodbyes” and explain the advantages of being apart from Parents or Siblings, such as spending time with friends at preschool.

School aged

For a school-aged youngster, the start of school is frequently the source of separation anxiety. In such instances, a parent should begin discussing what is about to occur before it occurs. It is necessary to begin talking about it a week in advance, including details concerning pick-up at the conclusion of the day. Furthermore, parents should discuss each future day with their children night before, and assist them in preparation. The less surprises there are, the better. Before kids have to go off on their own, it would be beneficial to show them their educational environment and meet the teachers.

A teen’s reluctance to attend or stay at school is frequently due to separation anxiety. Counseling can help anxious kids get back in gear, whether it is caused to by a nervous disposition, life stress, or the pandemic. It’s immensely gratifying to see teens overcome their separation anxiety with cognitive behavioral therapy. Such tactics assist the adolescent in examining their fear, anticipating situations where it is likely to emerge, and comprehending its consequences. When kids feel empowered and given the correct tools, the process can be surprisingly swift.

The goal of post-surgical treatment is for a child’s intestine to restore function so that it can operate by itself. A newborn will have a lot of watery bowel movements just after the operation, leading them to lose a lot of critical fluids and minerals. To compensate for these losses, the infant will pee in order to get nourishment and fluids via an intravenous (IV) line. Parents must ensure that their children sleep when they are weary, but also take them for a walk every day. Getting adequate sleep can help you recover faster. Following surgery, a child’s appetite may be affected. However, it is critical that they consume a nutritious diet.

Postoperative patients must be constantly monitored and checked for any signs of worsening, and the appropriate postoperative care plan or pathway must be followed. If a child is in pain when they wake up after surgery, it’s critical to diagnose and treat it as quickly as possible. Inadequately handled pain will simply add to the child’s worry and anxiety during his or her hospital stay. Because self-reporting is the only direct measure of pain, it is frequently regarded the best technique. However, there are a variety of situations in which youngsters find it difficult or impossible to express their own discomfort levels. A proxy measure must be employed in children who are cognitively challenged, extremely ill, or too young to talk.

In order to assess pain in newborns and young children, age-appropriate scales must be used. CRIES (Crying, Oxygen Requirement, Increased Vital Signs, Facial Expression, and Sleep) is the first tool. Based on changes from baseline, an observer assigns a score of 0-2 to each parameter. The Neonatal/Newborns Pain Scale (NIPS) has been utilized mostly in infants under the age of one year. Before, during, and after an operation, a numeric value is given to each of the following: facial expression, cry, breathing pattern, arms, legs, and state of arousal. A score of more than 3 indicates that the person is in agony.

From 2 months to 7 years, the FLACC (Face, Legs, Activity, Crying, Consolability) measure has been validated. The scoring system is based on a scale of 0 to 10. The CHEOPS scale (Children’s Hospital of Eastern Ontario Scale) is for children aged 1 to 7. Examines the child’s cry, facial expression, verbalization, torso movement, whether the youngster touches the affected area, and leg posture. A pain score of more than 4 indicates that the person is in pain. Children aged 3 and above can use self reporting to rank their pain. Wong-Baker 6 cartoon expressions with varying degrees of distress on a scale of one to six. Face 0 means “no pain,” while face 5 means “worst pain you can conceive.” At the time of the assessment, the kid selects the face that best portrays pain.

American Psychiatric Association. (n.d.). Separation Anxiety . APA Dictionary of Psychology. Web.

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SEPARATION ANXIETY DISORDER IN YOUTH: PHENOMENOLOGY, ASSESSMENT, AND TREATMENT

Jill t. ehrenreich.

1 University of Miami

Lauren C. Santucci

2 Boston University (USA)

Courtney L. Weiner

Separation Anxiety Disorder (SAD) is the most commonly diagnosed and impairing childhood anxiety disorder, accounting for approximately 50% of the referrals for mental health treatment of anxiety disorders. While considered a normative phenomenon in early childhood, SAD has the potential to negatively impact a child’s social and emotional functioning when it leads to avoidance of certain places, activities and experiences that are necessary for healthy development. Amongst those with severe symptoms, SAD may result in school refusal and a disruption in educational attainment. This paper provides a comprehensive review of the current literature on SAD etiology, assessment strategies, and empirically supported treatment approaches. New and innovative approaches to the treatment of SAD that also employ empirically supported techniques are highlighted. In addition, future directions and challenges in the assessment and treatment of SAD are addressed.

Anxiety disorders are one of the most common forms of psychopathology in youth, with prevalence estimates ranging from 5% to 25% worldwide ( Boyd, Kostanski, Gullone, Ollendick, & Shek, 2000 ; Costello, Mustillo, Erklani, Keeler, & Angold, 2003 ; Essau, Conradt, & Petermann, 2000 ; Roza, Hofstra, van der Ende, & Verhulst, 2003 ; Wittchen, Nelson, & Lachner, 1998 ). Of these, separation anxiety disorder (SAD) is the most frequently diagnosed childhood anxiety disorder, accounting for approximately 50% of the referrals for mental health treatment of anxiety disorders ( Bell-Dolan, 1995 ; Cartwright-Hatton, McNicol, & Doubleday, 2006 ).

Separation Anxiety Disorder is characterized by “developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached” ( American Psychiatric Association [APA], 2000 ). Children exhibiting SAD symptoms become significantly distressed when separated from their home or attachment figure (usually a parent) and will often take measures to avoid separation. This fear is exhibited through disproportionate and persistent worry about separation, including apprehension about harm befalling a parent or the child when they are not together, as well as fear that the parent will leave and never return. Avoidance behaviors commonly associated with SAD include clinging to parents, crying or tantruming, and refusal to participate in activities that require separation (e.g., play dates, camp, sleepovers).

Early in development, the experience of separation anxiety is a normal phenomenon that typically diminishes as the child matures. A diagnosis of SAD is only assigned when the child’s distress during separation is inappropriate given his or her age and developmental level ( APA, 2000 ). Research suggests that 4.1% of children will exhibit a clinical level of separation anxiety, and that approximately one-third of these childhood cases (36.1%) persist into adulthood if left untreated ( Shear, Jin, Ruscio, Walters, & Kessler, 2006 ).

Etiology of SAD in youth

There are several hypotheses regarding factors that contribute to the development and maintenance of SAD. Most current theories suggest that separation anxiety develops from an interaction of biological and environmental factors. Risk factors for SAD may include a genetic vulnerability to experience anxiety as well as temperamental and biological vulnerabilities ( Goldsmith & Gottesman, 1981 ). However, research suggests that SAD may be substantively influenced by environmental factors, more so than other childhood anxiety disorders ( Eley, 2001 ). In the Virginia Twin Study of Adolescent Behavioral Development (VTSABD), anxiety symptoms were assessed through child- and parent-report in 1412 same-sex twin pairs aged 8–16 years. Findings revealed that variance in child-reported SAD were attributable to both shared and non-shared environmental factors with no significant genetic influence ( Topolski et al., 1997 ). However, in a similar study including 2043 same-sex twin pairs aged 3–18, results indicated both shared-environment and genetic influences on SAD ( Feigon, Waldman, Levy, & Hay, 1997 ). Taken together, these findings suggest that environmental factors likely play a significant role in the development of SAD ( Vasey & Dadds, 2001 ).

One environmental factor frequently cited in the development of childhood anxiety is parenting behavior. Low parental warmth and parenting behaviors that discourage autonomy are associated with the development of anxiety and other childhood difficulties (see Ginsburg, Siqueland, Masia-Warner, & Hedtke, 2004 , for a review). Research in developmental psychology and attachment theory has consistently found that insecure or anxious attachment styles also serve as risk factors for various forms of emotional disturbance and psychopathology, including depression, anxiety, and behavior problems ( Foote, Eyberg, & Schuhmann, 1998 ; Sroufe, 2005 ; Westen, Nakash, Thomas, & Bradley, 2006 ). Additionally, research suggests that locus of control plays an etiological role, such that early childhood experiences promoting an external locus of control, or diminished sense of control over one’s environment, may serve as a risk factor for the development of anxiety ( Chorpita & Barlow, 1998 ).

Overprotective and over involved parenting behaviors are also central to the development and maintenance of childhood anxiety. Furthermore, parental intrusiveness appears to be a specific risk factor for SAD among children with anxiety disorder diagnoses ( Wood, 2006 ). In this context, intrusive parenting is characterized by disproportionate regulation of the child’s emotions and behavior as well as autocratic decision making. Parental intrusiveness is often enacted by providing excessive assistance in the child’s daily activities, such as dressing or bedtime routine, thus preventing the child from engaging in and mastering age-appropriate behaviors and activities. These intrusive parental behaviors, aimed at reducing or preventing the child’s distress, may instead encourage the child’s dependence on parents, thus impacting the child’s perceptions of mastery over his or her environment (see Wood, McLeod, Sigman, Hwang, & Chu, 2003 , for a review).

Effects of SAD on the developing child and family

Although SAD is relatively common, it can be extremely impairing to a child’s social and emotional development. Like most anxiety disorders, a common feature of SAD is avoidance of anxiety-provoking situations (e.g., separation from one’s attachment figure). Therefore, SAD has the potential to significantly impact one’s developmental trajectory if it leads to avoidance of certain places, activities and experiences that are crucial for healthy development. Children diagnosed with SAD often fear that something catastrophic might occur when they are separated from an attachment figure, leading to refusal to participate in developmentally appropriate activities with peers. In its most severe form, SAD may result in school refusal and a disruption in educational attainment. It has been estimated that approximately 75% of children with separation anxiety exhibit some form of school refusal behavior ( Last, Francis, Hersen, Kazdin, & Strauss, 1987 ). Longitudinal studies indicate that school refusal behavior can lead to serious short-term problems such as, academic decline, alienation from peers, and family conflict ( Kearney, 2006 ). Research also suggests that childhood SAD may significantly limit peer interactions, serving as a risk factor for future social impairment and isolation. For instance, childhood SAD may be associated with an increased risk of remaining unmarried or experiencing marital instability later in life ( Shear et al., 2006 ).

In addition to avoidance and clinging behaviors, children with SAD often display oppositional behaviors that can cause significant interference in family functioning and social development ( Tonge, 1994 ). When confronted with situations that require separation, such as bedtime or school attendance, a child with SAD may tantrum or refuse to comply with parents’ instructions. Oppositional behavior in the course of SAD often arises from the inadvertent reinforcement of the child’s avoidance behaviors and misconduct. For instance, when a child tantrums or “causes a scene,” parents may remove the child from the anxiety-provoking situation. As a result, these actions may reinforce the disruptive, inappropriate behavior.

Somatic symptoms, such as stomachaches, headaches and nausea, are another common feature of SAD. Children with SAD are also more likely to report somatic complaints of this nature than children diagnosed with phobic disorders ( Last, 1991 ). Somatic complaints often occur in the context of separation situations, reflecting either an avoidance strategy or genuine physical distress ( Albano, Chorpita, & Barlow, 1996 ; Tonge, 1994 ). In addition to more generalized somatic symptoms, children with SAD often experience sleep difficulties when a parent is not present and may refuse to sleep alone ( Black, 1995 ). Children with SAD may also experience nightmares about separation, potentially further disrupting sleep ( Francis, Last, & Strauss, 1987 ).

SAD may be significantly interfering not only for the child, but also for the attachment figure and other family members. Separation anxiety in one child affects overall family life and parental stress when the child’s anxiety limits the activities of siblings and parents ( Fischer, Himle, & Thyer, 1999 ). In the face of separation situations, children may have tantrums, cling to parents, or refuse to be left alone ( Tonge, 1994 ). Parents often make several accommodations (e.g., sleeping in the child’s bed, not leaving the child with other caregivers, forgoing quality time with a spouse) in order to alleviate the child’s distress. These accommodations can lead to distress among all family members. Parents may become frustrated that they are unable to spend time alone, while siblings may dislike that more attention is being paid to the symptomatic child. Additionally, it is not uncommon for a close bond to develop between the SAD child and one primary caregiver (most often the mother). This can lead to family dysfunction if that close relationship results in exclusionary behavior toward the father ( Bernstein & Borchardt, 1996 ).

Childhood SAD may also be associated with a heightened risk for the development of other anxiety and depressive disorders in adolescence and adulthood, such as panic disorder and agoraphobia (PDA; Biederman et al., 2005 ; Silove & Manicavasagar, 1993 ), though research findings are conflicting. Individuals with current PDA frequently report childhood histories of SAD. Furthermore, biological studies have found similar respiratory physiology among patients with SAD and PDA ( Battaglia, Bertella, Politi, & Bernardeschi, 1995 ; Silove, Harris, Morgan, & Boyce, 1995 ). However, Aschenbrand, Kendall, and Webb (2003) found that children diagnosed with SAD do not display a greater risk for developing PDA in adolescence and adulthood than those with other childhood anxiety diagnoses. Furthermore, subjects with a childhood diagnosis of SAD were not significantly more likely to meet diagnostic criteria for generalized anxiety disorder (GAD), social phobia, or major depressive disorder (MDD) in adulthood than subjects with childhood diagnoses of GAD or social phobia ( Aschenbrand et al., 2003 ). Due to these inconsistent findings, further research is warranted to determine whether childhood SAD serves as a distinctive risk factor for the development of particular anxiety and depressive disorders.

Diagnostic Interviews

Semi-structured and respondent-based interview measures are commonly utilized to determine whether a child meets diagnostic criteria for SAD, giving the clinician a framework for gathering important information about symptoms, including severity and frequency of presenting problems, and an opportunity to begin a functional analysis of such difficulties with the family. A commonly used diagnostic interview for the assessment of SAD is the Anxiety Disorders Interview Schedule for the DSM-IV, Child and Parent Version (ADIS-IV-C/P; Silverman & Albano, 1996 ). The ADIS-IV-C/P is a semi-structured interview that has proven useful in diagnosing children with a range of anxiety disorders including SAD, social phobia, specific phobias, GAD, and obsessive-compulsive disorder (OCD), in addition to mood disorders. The ADIS-IV-C/P has excellent psychometric properties, including good to excellent test-retest reliability for the diagnosis of anxiety disorders ( Silverman, Saavedra, & Pina, 2001 ) and evidence supporting its convergent validity ( Wood, Piacentini, Bergman, McCracken, & Barrios, 2002 ). This interview has been used extensively in the assessment of children with anxiety disorders ( Silverman et al., 2001 ; Westenberg, Siebelink, Warmenhoven, & Treffers, 1999 ). Children and their parents are interviewed separately and diagnoses are based on composite information from both reports ( Silverman & Nelles, 1988 ). This assessment procedure enables the clinician to gain precise knowledge of the child’s presenting symptoms, including the frequency, intensity, and duration, both from the perspective of the child and the parents.

Other commonly used diagnostic interviews that measure SAD symptoms as well as other forms of childhood psychopathology more broadly include the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version (K-SADS-PL; Kaufman et al., 1999 ) and the Diagnostic Interview Schedule for Children, Version IV (DISC-IV; Shaffer, Fisher, Lucas, Dulcan, & Schwab-Stone, 2000 ). The K-SADS-PL is a semi-structured diagnostic interview assessing current and past episodes of psychopathology in children and adolescents according to DSMIII- R and DSM-IV criteria. Similarly, the DISC-IV and its computerized counterpart, the C-DISC, are highly structured, respondent-based interviews designed to be administered by lay interviewers to assess commonly occurring psychological disorders of children and adolescents.

Assessment of preschool aged children

The majority of childhood anxiety assessment measures are developed for and validated with school-aged children, leaving disorders of early childhood relatively unexplored ( Angold & Egger, 2004 ). The paucity of diagnostic tools suitable for younger children has hindered our understanding of the etiology and developmental trajectory of early psychopathology, as well as the impact of early clinical intervention (see Egger & Angold, 2006 ). Given that SAD symptoms frequently have an onset prior to age six and that such symptoms in early childhood have been linked to later psychopathology, early identification and treatment of SAD is critical. In recent years, researchers have attempted to develop diagnostic criteria and assessment materials for preschool-aged children ( Task Force on Research Diagnostic Criteria, 2003 ). A small number of clinical interviews have also been developed in line with efforts to better understand the presentation of psychopathology in early childhood. For instance, the Preschool Age Psychiatric Assessment (PAPA; Egger, Ascher, & Angold, 1999 ) is a structured parent interview used to diagnose psychiatric disorders in children aged two to five. The PAPA is based on the Child and Adolescent Psychiatric Assessment (CAPA), but is adapted in form and content to be suitable for very young children. The PAPA is the first developmentally appropriate structured psychiatric interview to assess psychopathology, family and community risk factors, as well as resiliency and protective factors, in both community and clinical samples of preschool children as young as age two. It is hoped that the PAPA will contribute to the development of a reliable psychiatric classification system for early childhood. Research has found the PAPA to be a reasonably reliable measure of DSM-IV disorders in early childhood. Specifically, diagnostic reliability (kappa) ranged from .36 to .79, while test-retest intraclass correlations for DSM-IV syndrome scale scores ranged from .56 to .89. For the SAD subscale of the PAPA, diagnostic reliability was .60 and the test-retest intraclass correlation was .63. No significant differences in reliability were found by age, sex or race ( Egger et al., 2006 ).

Self-Report measures

While diagnostic interview measures are generally considered the “gold standard” for accurate and thorough assessment of DSM-IV criteria for SAD, these interviews are often lengthy, costly, and require some level of specialized training. When time and resources are more limited, self-report measures may also be collected from parents and children in the assessment of SAD, provided the child has the reading and/or writing skills to effectively respond to such questionnaires. The following measures have proven useful in the assessment and subsequent treatment of children presenting with separation anxiety and worries, although they should not be used in isolation for the diagnostic assessment of SAD.

Self-report measures with both parent and child versions

The Multidimensional Anxiety Scale for Children (MASC; March, Parker, Sullivan, Stallings, & Cibbers, 1997 ) is a 39-item, empirically derived, multi-domain self-report measure designed to assess a broad range of anxiety symptoms. Subscales on the MASC include Tense/Restless, Somatic/Autonomic, Total Physical Symptoms, Perfectionism, Anxious Coping, Total Harm Avoidance, Humiliation/Rejection, Performance Fears, Total Social Anxiety, Separation/Panic, and Total MASC score. A shorter, ten-item form (MASC-10) also exists. The ability of the MASC to assess a broad range of anxiety symptoms is particularly useful given the high levels of comorbidity between children and adolescents with SAD, GAD, OCD, and other anxiety disorders (see Curry, March, & Hervey, 2004 ). The MASC has significant empirical support demonstrating its validity and reliability as well as its factor structure ( March et al., 1997 ; March et al., 1999 ). Three-month test-retest reliability was found to be satisfactory to excellent, with all intra-class correlations above .60. Internal consistency was also found to be acceptable. A parent version of the MASC also exists and is often used for research purposes. However, the psychometric properties of this parent version are still being explored.

The 34-item Separation Anxiety Assessment Scale, Parent and Child Versions (SAAS-C/P; Eisen & Schaefer, 2007 ) measures specific dimensions of childhood SAD based on DSM-IV diagnostic criteria as well as related anxiety symptoms. The SAAS includes four symptom dimensions: Fear of Being Alone, Fear of Abandonment, Fear of Physical Illness, and Worry about Calamitous Events. In addition, the SAAS contains a Frequency of Calamitous Events subscale, as well a Safety Signals Index. Preliminary data support the factor structure, reliability, validity, and clinical utility of this measure ( Hahn, Hajinlian, Eisen, Winder, & Pincus, 2003 ; Hajinlian et al., 2003 ; Hajinlian, Mesnik, & Eisen, 2005 ).

The Spence Children’s Anxiety Scale (SCAS; Spence, 1997 ) assesses anxiety by both parent and child report. The scale measures a wide range of anxiety symptoms, has a specific factor/scale assessing separation anxiety symptoms, and provides information about other anxiety disorder symptoms. The subscales include separation anxiety, panic/agoraphobia, social anxiety, generalized anxiety, obsessions/compulsions, and fear of physical injury. The six subscale structure of the SCAS has been established by confirmatory factor analysis ( Spence, 1997 ; Spence, 1998 ). Total internal consistency of .92 has been found across studies while internal consistency of the separation subscale ranges from .62 to .74 ( Muris, Merckelbach, Ollendick, King, & Bogie, 2002 ; Muris, Schmidt, & Merckelbach, 2000 ; Spence, 1998 ; Spence, Barrett & Turner, 2003 ). Three and six month test-retest reliabilities of .60 and .63, respectively, were reported for the total score ( Spence, 1998 ; Spence at el., 2003 ). A preschool version of the SCAS is also available. The Preschool Anxiety Scale ( Spence, Rapee, McDonald, & Ingram, 2001 ) relies on parent self-report of anxiety symptoms with normative data available for children two to six years of age. While this measure is in development, promising validity information has been established using confirmatory factor analysis ( Spence et al., 2001 ).

The Screen for Child Anxiety Related Emotional Disorders-Revised (SCARED-R; Muris, Merckelbach, Schmidt, & Mayer, 1999 ) is a self-report questionnaire for children as young as age seven. A parent version of this measure also exists. The SCARED-R contains 66-items measuring all DSM-IV anxiety disorders occurring in children and adolescents, including 8-items assessing SAD specifically. In a sample of clinically referred youth, most scales of the SCARED-R were reliable in terms of internal consistency, and cronbach’s alpha of .72 for the child version and .81 for the parent version were found for the SAD subscale. Furthermore, parent-child agreement was reasonable, with correlations of .69 for the total score and .62 for the SAD subscale reported. Convergent and discriminant validity were also established, as SCARED-R total scores were significantly associated with CBCL Internalizing Problems but not with Externalizing Problems ( Muris, Dreessen, Bogels, Weckx, & van Melick, 2004 ).

Additional self-report measures

When addressing separation anxiety, precise assessment of avoidance behaviors may be crucial to subsequent cognitive-behavioral treatment. The Fear and Avoidance Hierarchy (FAH) , commonly used in many cognitive-behavioral approaches in the treatment of anxiety, operationally defines the “top 10” anxiety provoking situations for the child, and serves as a measure of treatment progress. Depending on the age of the child, the FAH can be completed by the parent or the parent and child together. Each anxiety provoking situation or item listed by the child is rated separately for level of fear and degree of avoidance on a 0 (not at all) to 8 (extreme) Likert-type scale. The inclusion of the avoidance rating may help later in treatment when designing particular exposures for the child. The FAH provides an ecologically valid method of defining the behavioral limits of a child’s separation anxiety, and has been used extensively with childhood anxiety disorders, such as social phobia and specific fears ( Albano & Barlow, 1996 ). It is recommended that the child and his or her parent(s) complete the FAH with the help of the clinician, who can assist in drawing out the separation situations that may need to be addressed in treatment.

Other widely used rating scales for anxiety symptoms in children and adolescents include the Fear Survey Schedule for Children-Revised (FSSC-R; Ollendick, 1983 ), the Revised Child Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1978 ), the Stait-Trait Anxiety Inventory for Children (STAIC; Spielberger, Gorsuch, & Luchene, 1970 ), and the Social Phobia and Anxiety Inventory for Children (SPAI-C; Beidel, Turner, & Morris, 1995 ). In addition to the MASC, these measures can provide significant information on a range of anxiety difficulties in children. However, the MASC conveniently assesses the broad cross-section of childhood DSM-IV anxiety difficulties in a single measure ( March, 1997 ).

Assessment of parent-child interaction

Parent-child interaction factors have long been implicated in the etiology and maintenance of childhood anxiety disorders (e.g., Ainsworth, Blehar, Waters, & Wall, 1978 ). Thus, within a comprehensive psychological assessment, direct behavioral observation is extremely important and beneficial, particularly with children ( Ciminero, 1986 ; McMahon & Forehand, 1988 ). Such observation is also necessary due to the incomplete results often produced by self-report measures, especially when assessing inappropriate behavior, such as the avoidant behavior characteristic of children with SAD ( Hartmann & Wood, 1990 ). While behavioral observation protocols are not diagnostic tools, they enable the assessment of interaction factors thought to contribute to childhood SAD and parent-child responding to the separation context. The development of the Dyadic Parent-Child Interaction Coding System (DPICS; Eyberg & Robinson, 1983 ) and the subsequent Dyadic Parent-Child Interaction Coding System II (DPICS II; Eyberg, Bessmer, Newcomb, Edwards & Robinson, 1994 ) has provided the clinical community with one direct observational-based method for assessing parent-child interactions. It is especially important to address such interactions in children with separation anxiety because these interactions, when maladaptive, form the core construct of the disorder. Psychometric data for the DPICS II has proven to be good to excellent ( Deskin, 2005 ).

The DPICS II contains categories of both parent and child behavior, including behavioral descriptions, informational descriptions, questions, commands, labeled and unlabeled praise, and criticism. Administered in a specific protocol, the DPICS II includes three phases of a brief play interaction between the child and parent. In phase one (Child Directed Interaction; CDI), the child is encouraged to lead the play while the parent attempts to create a positive, non-directive environment. In the second phase of the interaction (Parent Directed Interaction; PDI), the parent directs the play. In the final phase (Clean-up; CU), the child is instructed to clean up the playroom ( Eyberg et al., 1994 ).

The DPICS II and its coding system have been recently modified for use with young children with separation anxiety and their families ( Pincus, Cheron, Santucci & Eyberg, 2006 ). By adding a fourth observational phase (Separation; SEP), in which the parent briefly leaves the room and the child is told to play with a confederate, the clinician is privy to the types of behaviors the child might exhibit during periods of acute separation. The DPICS II, as modified for children with separation anxiety, can be useful not only for assessment, but also for monitoring treatment progress, outcome, and maintenance of gains over time.

As noted previously, research has pointed to parental intrusiveness as a specific risk factor for childhood SAD ( Wood, 2006 ). To assess the parent-child interaction and parental intrusiveness specifically, the following four measures have been combined into The Composite Parental Intrusiveness Scale by Wood (2006) : a belt-buckling task that is videotaped and later coded for intrusive behavior, Parent- Child Interaction Questionnaire, Parent and Child versions (PCIQ), and Skills of Daily Living Checklist (SDLC). This composite scale has been found to have favorable psychometric properties. Convergent and discriminant validity have been established through a multitrait-multimethod matrix ( Wood, 2006 ). Importantly, the Composite Parental Intrusiveness Scale has been found to mediate treatment outcome and to be responsive to parent-training ( Wood, 2006 ).

Although childhood anxiety disorders are amongst the most common forms of developmental psychopathology, efficacious treatments have only been introduced and evaluated in the last 20 years. Currently, the treatment with the most evidence supporting its efficacy in ameliorating childhood anxiety disorders, including SAD, is cognitive behavior therapy (CBT; Kazdin & Weisz, 1998 ; Velting, Setzer, & Albano, 2004 ). Cognitive behavior therapy utilizes both cognitive restructuring and exposure techniques to reduce anxiety and enable anxious individuals to cope more effectively with their anxiety. Additionally, CBT often includes psychoeducation about the nature and treatment of anxiety and anxiety reduction techniques, including breathing retraining and progressive muscle relaxation. While several controlled studies have shown the efficacy of CBT for anxiety disorders in children and adolescents ( Barrett, Dadds, & Rapee, 1996 ; Kendall, 1994 ; Kendall et al., 1997 ), the majority of these investigations have excluded youth under the age of seven ( Table 1 ).

Randomized clinical trials for child anxiety including children with SAD

Note: Abbreviations for therapy types: FCBT = family involvement cognitive-behavioral therapy; CCBT = child-focused cognitive-behavioral therapy; CPT = cognitive parent-training; GCBT = group cognitive-behavioral therapy; ICBT = individual cognitive-behavioral therapy; FGCBT = group cognitive-behavioral therapy with significant family component, ES = Educational Support Therapy, PAM = Parental Anxiety Management.

Abbreviations for sample: SocP = social phobia; OAD = over-anxious disorder; SAD = social anxiety disorder; SP = Specific Phobia, GAD = generalized anxiety disorder; AD = avoidant disorder; AdjD = Adjustment Disorder; PD(A) = Panic Disorder with or without Agoraphobia.

Other abbreviations: WL = waiting list control; KSCID = Kids Semi-structured Clinical Interview for DSM-IV diagnoses; ADIS = Anxiety Disorders Interview Schedule; ADIS-C = Anxiety Disorders Interview Schedule-Children; ADIS-P = Anxiety Disorders Interview Schedule-Parents; MASC = Multidimensional Anxiety Scale for Children; CGAS = Children’s Global Assessment Scale; RCMAS = Revised Children’s Manifest Anxiety Scale; CDI = Children’s Depression Inventory; CCSC = Children’s Coping Strategies Checklist; K-SADS-P = Kiddie-Schedule for Affective Disorders and Schizophrenia - Parents; GIS = Global Improvement Scale.;

The Coping Cat program ( Kendall, 1990 ) is a popular manualized CBT intervention for youth with anxiety disorders, including SAD. The program incorporates cognitive restructuring and relaxation training followed by gradual exposure to anxiety-provoking situations while applying the coping skills learned in previous sessions ( Grover, Hughes, & Bergman, 2006 ). The Coping Cat program was evaluated in a randomized controlled trial (RCT; Kendall, 1994 ) including 47 children between the ages of eight and 13. All study participants met diagnostic criteria for GAD, SAD, or Social Phobia and were randomly assigned to either a 16-week treatment or waitlist control condition. Results revealed that children in the treatment condition had significantly better outcomes than those assigned to waitlist. At post-treatment, 66% of the participants who followed the Coping Cat program no longer met criteria for an anxiety disorder versus only 5% in the waitlist condition. Long-term follow-up assessments conducted at three years and seven and a half years revealed maintenance of treatment gains over time ( Kendall & Southam-Gerow, 1996 ; Kendall, Safford, Flannery-Schroeder, & Webb, 2004 ). These promising results were replicated in a second RCT including 94 anxious youth ages nine to 13, again randomly assigned to a waitlist control or the Coping Cat treatment program. Over 50% of youth in the treatment condition were free of their primary diagnosis at post-treatment ( Kendall et al., 1997 ).

Family involvement in the treatment of SAD is often recommended because of the parent’s integral role in the maintenance of children’s separation fears. The FRIENDS program ( Barrett, Lowry-Webster, & Turner, 2000 ) is a 10-session CBT intervention for children with anxiety disorders that is delivered in a group format. The program includes all of the essential components of CBT, such as cognitive restructuring and systematic exposure, but also incorporates family involvement and elements of interpersonal therapy. For instance, cognitive restructuring for parents is included in the program and families are encouraged to develop supportive social networks. Parents are encouraged to practice the FRIENDS skills with their children on a daily basis and provide positive reinforcement when skills are used appropriately. In addition to the importance of parental involvement, the program promotes peer involvement and interpersonal support through an emphasis on developing friendships, talking to friends about difficult situations, and learning from peers’ experiences.

FRIENDS is an acronym that stands for: F—Feeling worried?; R—Relax and feel good; I—Inner thoughts; E—Explore plans, N—Nice work so reward yourself; D—Don’t forget to practice; and S—Stay calm, you know how to cope now. The FRIENDS program was systematically evaluated in a RCT including 71 children aged six to 10 who met diagnostic criteria for GAD, SAD or Social Phobia ( Shortt, Barrett & Fox, 2001 ). Subjects were randomly assigned to either a treatment or waitlist control condition. Results indicated that 69% of children in the FRIENDS program versus only 6% of controls no longer met diagnostic criteria for an anxiety disorder at post-treatment. For study participants in the treatment group, therapeutic gains were maintained at a one-year follow-up assessment.

As previously mentioned, both parent and child participation is often recommended for SAD treatment. However, preliminary research suggests that direct child involvement may not be necessary. A recent study by Eisen and colleagues (2008) examined the efficacy of an integrated cognitive-behavioral parent-training intervention specifically targeting the parents of SAD youth. Using a multiple baseline design, six families were included in the study, each with a child (seven to 10 years of age) who met diagnostic criteria for SAD. The treatment protocol included 10 parent-only sessions and incorporated traditional cognitive-behavioral techniques such as psychoeducation, in-session practice, imaginal exposure, and homework assignments. Following the treatment, 5 of the 6 child participants no longer met diagnostic criteria for SAD, and the sixth child was assigned a subclinical SAD diagnosis. Additionally, the intervention led to clinically significant improvement on measures of parental self-efficacy and stress.

As previously noted, most investigations of CBT for childhood anxiety disorders, including SAD, have investigated treatment outcome only for children aged 7 and older. This age cutoff is pragmatic, given the slightly more sophisticated cognitive and reasoning skills required for learning certain CBT skills, such as cognitive restructuring. However, given that SAD symptoms often manifest in children under seven, the common usage of this age-based exclusion criteria means that we know relatively little about effective treatments for young children with SAD. Recently, Parent-Child Interaction Therapy (PCIT; Brinkmeyer & Eyberg, 2003 ) has been adapted specifically for young children with SAD ( Choate, Pincus, & Eyberg, 2005 ; Pincus, Eyberg, Choate, & Barlow, 2005 ). Parent-Child Interaction Therapy, as developed for the treatment of SAD in children aged four to eight, incorporates three treatment phases: Child-Directed Interaction (CDI), Bravery-Directed Interaction (BDI), and Parent-Directed Interaction (PDI). The CDI phase focuses on improving the quality of the parent-child relationship. Parents are taught interaction skills that focus on parental warmth, attention, and praise, which ultimately facilitate the child’s development of internal attributions of self-control. The improved attachment and warmth elicited by CDI may help strengthen the child’s feeling of security and thus encourage separation from the parent with less distress. Differential reinforcement, or the praising of appropriate behavior and ignoring of undesirable behavior, provides a positive and effective method of behavior management.

The BDI phase begins with psychoeducation for parents about the nature of anxiety and explains the rationale for gradual exposure to anxiety-provoking separation situations. The therapist works with both the parent(s) and the child to develop a fear hierarchy, or “bravery ladder,” that lists each situation of which the child is fearful and/or currently avoiding. Additionally, the family creates a reward list to reinforce the child’s approach behaviors to these feared situations.

In the final stage of treatment, PDI, methods of incorporating clearly communicated and age-appropriate instructions to the child are taught to parents as a means of managing misbehavior. Using techniques based directly on operant principles of behavior change, parents are taught to provide consistent positive and negative consequences following the child’s obedience and disobedience. In addition, the therapist assists the parents in understanding how a child’s behavior is shaped and maintained by his or her social environment. For instance, parents may inadvertently reinforce anxious behaviors by giving the child more attention, thus increasing the likelihood of those behaviors in the future ( Eisen, Engler, & Geyer, 1998 ).

During all three stages of PCIT, parents are actively coached on how to apply the skills during a play-task with their child. Coaching occurs through a one-way mirror, using a “bug-in-the-ear” (walkie-talkies and an ear-piece microphone) to communicate with and provide instruction to the parents. Mastery is measured by the parents’ ability to utilize a specified number of each skill demonstrated during an observed interaction task.

The first RCT to investigate the efficacy of using PCIT to treat young children with SAD is in its final stages of completion. Currently, 45 children with a principal diagnosis of SAD have been randomly assigned to one of two conditions following a pre-treatment assessment. In the treatment condition, participants receive an immediate course of PCIT over approximately nine weekly sessions. Those assigned to the waitlist condition are required to wait nine weeks prior to receiving treatment, after which the family receives a post-waitlist assessment prior to beginning the active treatment phase. Preliminary analyses indicate that children with SAD evidenced clinically significant improvement following the intervention, with continued improvement over time ( Pincus, Santucci, Ehrenreich, & Eyberg, in press ).

Another new treatment for SAD, in which CBT skills are delivered in a one-week “summer camp” format, is currently being evaluated for school-aged girls with SAD ( Santucci & Ehrenreich, 2007 ). A potential benefit of a camp-based, group approach for SAD is the incorporation of children’s social context into treatment. Whereas many school-aged children are spending increasing time with their peers and away from parents, children with SAD often exhibit increased clinginess and attachment to parents. Additionally, providing treatment in a group format allows for more naturalistic exposure possibilities regarding typical separation situations, such as group field trips, activities, and sleepovers. The program also includes a parent component aimed to increase parent education about management of SAD behaviors. Throughout the week, parent involvement is systematically decreased in order to gradually expose children to anxiety-provoking separation situations.

The summer treatment program for SAD was pilot tested using a multiple-baseline design across participants with five female children, aged eight to 11, all meeting diagnostic criteria for SAD at pre-treatment. Results from this initial investigation revealed significant changes in diagnostic status across all participants ( Santucci, Ehrenreich, Bennett, Trosper, & Pincus, 2007 ). Specifically, severity of the SAD symptoms decreased substantially at post-treatment for each subject. Immediately following treatment, three participants no longer met diagnostic severity criteria for the disorder and, by two month follow-up, none of the participants met criteria for a clinical diagnosis of SAD, suggesting an even greater generalization of treatment effects over time. Reductions in severity of other comorbid anxiety diagnoses not specifically targeted by the intervention were also observed and, by two month follow-up, only one participant met criteria for any clinical-level diagnosis.

In addition, another manualized CBT intervention for anxiety disorders in children aged four to seven is currently under investigation that may have benefit for young children with SAD ( Hirshfeld-Becker & Biederman, 2002 ). This early-intervention program focuses on identifying children at risk for developing an anxiety disorder and utilizes cognitive-behavioral techniques appropriate for preschool-age children. A substantial parental component is included in the program in order to teach parents techniques to effectively manage their child’s anxious symptoms and behaviors.

Finally, numerous pharmacological treatments for childhood anxiety have been investigated with mixed results. While medication for SAD is not usually recommended as a first line of treatment, it is possibly a useful strategy for CBT nonresponders ( Masi, Mucci, & Millepiedi, 2001 ). Research suggests that selective serotonin reuptake inhibitors (SSRIs) may have therapeutic effects for children and adolescents with anxiety disorders ( Reinblatt & Riddle, 2007 ). Two RCTs have supported the use of SSRIs in children and adolescents with SAD, GAD, and Social Phobia. In an eight-week RCT investigating the use of fluvoxamine in treating children and adolescents diagnosed with SAD, GAD, or social phobia, fluvoxamine was found to be significantly more efficacious than placebo in decreasing anxiety symptoms ( RUPP Anxiety Study Group, 2001 ). At the end of the eight-week study period, 76% of the children taking fluvoxamine were doing significantly better versus only 29% of the children who received a placebo, using the Pediatric Anxiety Ratings Scale (PARS; Research Units on Pediatric Psychopharmacology Anxiety Study Group, 2002 ) and the Clinical Global Impressions-Improvement Scale (CGI-S; Guy, 1976 ) to measure improvements in symptomatology. Birmaher et al. (2003) demonstrated the efficacy of fluoxetine in a 12-week RCT including 37 youth with SAD, GAD, and/or social phobia. Subjects in the active treatment condition were found to be less symptomatic than those assigned to the placebo condition at post-treatment. At one-year follow-up, the fluoxetine group showed significantly greater improvement than the placebo group. Additionally, 30% of those in the placebo group were rated as “not improved” by independent evaluators versus only 5% of those who received fluoxetine ( Birmaher et al., 2003 ).

Future directions

Separation anxiety disorder is an impairing and costly difficulty that is common amongst younger children and those in their early school years. While separation anxiety often prompts parents and school professionals to seek clinical assistance for children experiencing more severe symptoms, the knowledge base regarding the etiology, assessment and treatment of this disorder is still clearly in development. There are several burgeoning areas of research regarding SAD that could benefit from additional attention, many of which have already been alluded to in this review. Amongst these, the need for additional investigation of assessment, treatment, and preventative intervention methodology appropriate for younger children (below age seven) is clearly paramount. In addition, further research regarding the role of parenting, temperament, and other etiological variables in the environment of children with SAD symptoms appears warranted, as well as clarification of subsequent risks for further psychopathology development.

Young children without developmental disabilities have rarely been the target of clinical assessment and intervention research. Separation anxiety, recognized as a normative fear during a child’s early development, typically begins to diminish after approximately 30 months of age. For those children that continue to demonstrate distressing and interfering separation fear or avoidance symptoms, the options for broader assessment of symptomatology are generally lacking. Other than those few measures cited previously as having been or currently being normed with preschool-aged children (the PAPA; Preschool Anxiety Scale), research on assessment has failed to keep up with the burgeoning treatment investigations regarding younger children with SAD. Moreover, while the Preschool Anxiety Scale is available online, relatively few similar tools are available to clinicians working outside the research domain. Without the development and evaluation of appropriate, clinically-relevant tools for the assessment of SAD symptoms, impairment, general functioning, and family environment in this younger population of children with SAD, research regarding etiology and appropriate treatment will continue to lag behind investigation of older children and those with other clinical anxiety disorders.

Investigation of treatments for younger children with SAD has similarly lagged behind treatments for older children. As noted in this review, new research regarding PCIT for SAD and other parent-focused interventions has greatly expanded our knowledge base regarding intervention for those who present for such treatment. However, a focus on those with only clinically-significant separation fears fails to account for those parents who have difficulty coping with their young child’s separation fears, despite the fact that this demonstration of anxiety might be normative. Perhaps providing families with early intervention strategies, even for separation fears deemed developmentally appropriate, might protect the parents and the child from a later exacerbation of symptoms. Similarly, the presentation of brief, preventative intervention strategies at times of difficult transition for children with separation anxiety symptoms (e.g., transition to kindergarten, camps) may also target children that might struggle with such transitions but have yet to be identified or for whom current symptoms might only present in particular domains. In addition, given that parental behaviors such as intrusiveness have been linked specifically to SAD, early parent training might also have the potential to alter the course of the development of child psychopathology.

Further research is also needed in the understanding of the etiology of SAD, beyond the genetic risk factors and parenting behaviors known to contribute to the manifestation and maintenance of the disorder. Although recent research into parental intrusiveness (e.g., Wood, 2006 ) and similar efforts have shed light on parenting factors associated with SAD and subsequent implications for parent involvement in treatment, more research is still needed to better understand the full scope of developmental influences on and trajectory of children with SAD. Investigation into potential pathways from SAD to other specific anxiety disorders could greatly inform treatment strategy. If specific pathways are identified, such as SAD leading to GAD, PDA, or OCD, research can investigate whether treatment should differ based on these various trajectories. For instance, a child exhibiting compulsive checking rituals surrounding parental separation might most benefit from exposure and response prevention, while treatment for a child exhibiting somatic sensitivity related to separation could be tailored to include a more robust somatic awareness component. Such attentiveness to the etiology of SAD and the links between SAD and subsequent prevention and treatment options for children both younger and older would greatly expand the research base regarding separation anxiety in youth.

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What Is Separation Anxiety?

Any parent who has handed over a reluctant child to a caregiver has seen separation anxiety in action. Separation anxiety is a condition in which a person feels extreme fear or distress when separated from an emotional attachment, such as a parent, a loved one, or a place they feel safe, like their home. While the tears can be heartbreaking, the good news is separation anxiety is a normal part of child development and usually gets easier with time. 

Verywell / Brianna Gilmartin

When separation anxiety occurs in older children, adolescents, or adults, or when it causes debilitating anxiety, it is considered separation anxiety disorder (SAD). Unlike typical separation anxiety, SAD is intrusive and may require treatment such as behavioral therapy, other psychotherapies, positive reinforcement, or medications, depending on the person’s age and the severity of their symptoms. 

Some symptoms of SAD overlap with symptoms of panic disorder and other types of anxiety disorders . If you suspect you or your child has SAD, it’s a good idea to see a healthcare provider to get a nuanced and accurate diagnosis.

Separation Anxiety Confusion

While they are all known by the abbreviation SAD, separation anxiety disorder, social anxiety disorder, and seasonal affective disorder are different mental health conditions and should not be confused.

Have you ever wondered why babies love peek-a-boo? It all has to do with object permanence. Before a baby develops object permanence, things (and people) really are “out of sight, out of mind.” 

At about the age of 8 months, babies develop a sense of selfhood and begin to learn object permanence but don’t quite fully comprehend its complexities. They know they exist separate from other people, and they understand that a parent or loved one exists even after they have left their presence, but they aren’t always convinced their beloved person is coming back. 

This normal developmental stage usually starts when a baby is about 8 months old and can last until a child is 3 or 4 years old.

This anxiety can rear its head even if the child knows and trusts the person in whose care they have been placed. Ask any childcare provider, and they will tell you how frequently a child will cry when dropped off, then quickly settle in once their parent has left.

As a child matures emotionally, and begins to trust that people who leave come back, separation anxiety tends to resolve on its own. 

While separation anxiety is a normal part of development in young children, it is not considered typical in older children, teens, and adults. When separation anxiety occurs in people outside of early childhood and has a negative impact on the individual’s well-being, social functioning, family life, academic or work performance, and physical health, it may be regarded as SAD.

Accounting for 50% of diagnoses in children seeking treatment for mental health, SAD is the most common pediatric anxiety disorder. By adolescence, roughly 8% of youth have met diagnostic criteria for SAD at some point in their lives.

Though we tend to associate separation anxiety with children, some research suggests that at some point in their lives, up to 6.6% of adults will experience SAD.

When To Worry About Separation Anxiety

Separation anxiety is a normal part of a child’s development and cognitive maturation, not a behavioral problem. It should only be considered a problem if it interferes with a child’s quality of life or delays development.

Every child has meltdowns, even older children. 

The occasional emotional outburst does not indicate SAD. SAD is characterized by persistent and extreme emotions and behaviors both with separation and in anticipation of separation from a major attachment figure such as a parent or grandparent, from home, or both.

Common symptoms of SAD include:

• Distress related to separation
• Excessive worry about losing or harm coming to the attachment figure
• Worry that an event will cause a separation from the attachment figure
• Reluctance or refusal to go to places such as school
• Fear of being alone or without the attachment figure
• Reluctance to sleep away from the attachment figure
• Nightmares about separation
• Physical symptoms associated with separation

SAD can manifest in physical symptoms, including:

• Stomachaches
• Bed-wetting

School is a major stressor for older children with SAD. An older child or adolescent may exhibit school-specific behaviors like feigning illness or experiencing headaches, stomachaches, and other ailments when it is time to go to school. These illnesses go away once the child is allowed to stay home but reappear before school the next day. 

They may refuse to go to school or to say goodbye, or they may have “meltdowns” involving prolonged screaming and crying.

For older children, SAD symptoms are not limited to times of separation. SAD can manifest in a number of ways even when the child is home and/or with their parent or loved one. Older children with SAD may:

• Feel anxious being alone in a room
• Be “clingy”
• Worry excessively about something happening to themselves, their parents, or their loved ones
• Stay close to parents, even within the home
• Have exaggerated and irrational fears of things like the dark, monsters, or burglars
• Have difficulty sleeping

While for children, the attachment figure is usually a parent or guardian, for adults it may be a spouse, a partner, or a friend. 

Adult separation anxiety disorder (ASAD) can be debilitating. ASAD can cause problems with job performance, including lack of concentration, coming in late or leaving worry, or difficulty maintaining employment. 

People with ASAD may also have difficulties with social and romantic relationships. Often, the subject of the attachment becomes distressed or annoyed by the neediness of the person with ASAD. Sometimes what we call “drama” is a person exhibiting symptoms of ASAD.

ASAD may manifest when a person is dealing with the breakdown of a relationship or the death of a loved one. A parent may even suffer from ASAD when their child becomes more independent and no longer relies solely on them for companionship.

If your child is still experiencing separation anxiety past the age of 3 or 4 when it is developmentally normal, SAD may be the culprit. When suspected, SAD is usually diagnosed after the age of 6 or 7.  

For a diagnosis of SAD, both adults and children must meet three of the eight conditions outlined in the Diagnostic and Statistical Manual of Mental Disorders, Edition 5 (DSM 5); however, the assessment tools differ by age.

To be diagnosed with SAD, children must show symptoms for at least four weeks. To meet the criteria for a SAD diagnosis, adults must experience symptoms that impair function for at least six months.

To diagnose adults with SAD, healthcare providers primarily rely on self-reports. Because children cannot reliably be assessed with adult self-reports, parents and healthcare providers must use other methods.

The Children’s Separation Anxiety Scale (CSAS) lists child-accessible questions such as, “Does your belly hurt when you have to leave your mom or dad?”, and “Do you worry about getting lost?” that can help a healthcare provider assess if a child is experiencing symptoms of SAD.

Parents can play a big part in their child’s assessment by relaying observations they have made of their child. A healthcare provider may ask parents to note their observations in a structured document known as a Separation Anxiety Daily Diary (SADD).

While scientists don’t fully understand what causes SAD, they believe it is related to biological, cognitive, and environmental factors.

Environment

SAD symptoms often appear after a change or stress in a child’s life. Even a positive change can cause a child to feel anxious. Some changes that might trigger or exacerbate SAD include:  

• A change in caregiver
• A change in routine
• A traumatic event
• A change in parental availability or discipline
• A change in family structure, such as divorce or separation, a death, birth of a sibling, or parental illness
• Lack of adequate rest
• A family move
• Starting a new school, or returning to school after time away

Parental Mental Health

• Data suggests that SAD is 20 to 40% heritable, meaning that it can be inherited from a biological parent.   This suggests that a child is more likely to develop SAD if they inherit certain temperamental and anxious vulnerabilities from their parents.

Parenting Style

Parenting style is linked to attachment theory—how our early experiences with attachment affect our mental health and our ability to bond with other people.

SAD appears to be associated with attachment anxiety—anxiety experienced about relationships with people who are important in our lives.

Parenting that is overly critical, overly controlling, or overprotective can interfere with a child’s development of autonomy, and contribute to anxiety disorders. The effects of parenting style are seen both in childhood and after a person enters adulthood.

Temperament

Children with SAD do not like change. When something is new or different, they tend to react negatively   and respond with avoidance, fear, or suspicion. They can also have a difficult time self-regulating their emotions when they feel anxious or scared. 

Adults with SAD try to avoid confrontation. They also tend to lack self-directedness—the ability to be goal-oriented, resourceful, and adaptive to situations.

How socioeconomic status (SES) affects childhood anxiety is complex and depends on a number of factors including the type of anxiety, and if income is evaluated at an individual household level or a neighborhood level.  

Most children with anxiety disorders come from middle- to upper-income families. In contrast to this, those with SAD tend to come from low-income homes. This suggests that financial stresses within a family may lead to insecurity in younger children.

Contingency Management

This treatment is based on positive enforcement.   The child and the parent agree on a set of goals. When the child meets the goals, the parent gives them a reward. The reward can be anything the child finds valuable, be it a sticker, a toy, or even extra TV time. Contingency management operates on the principle that behaviors that get rewarded get repeated.

Cognitive Behavioral Therapy (CBT)

The first go-to treatment for SAD is CBT. Studies show it to be an effective treatment for anxiety disorders including SAD, without the side effects that can come with medication.  

CBT focuses on the “here and now” rather than the underlying cause of the condition. The goal of CBT is to change learning and thought patterns that are unhealthy or cause problems and replace them with ones that are adaptive and productive.

With CBD, it isn’t just the child whose approach and behavior needs to change. Parents, teachers, and other significant figures in the child’s life need to commit to changing their responses to the child’s anxiety, reinforcing the child’s progress.

Treatment usually takes twelve to sixteen weeks but may require “refresher” sessions here and thereafter treatment has finished.  

Exposure Therapy

Exposing children to the very things that scare them sounds counter-productive, or even mean. In reality, exposure therapy works on the principle that confronting your fears gives you the chance to see that they are innocuous, and helps you develop coping strategies to manage your anxieties. This probably sounds familiar. Does it call to mind the “face your fears” speeches given to most of us by our own parents?

Exposure therapy is more controlled than simply not running away from things that scare us. Treatment usually falls into four phases, worked through in order.  

• Instruction: Adults, or children with SAD and their parents, are given a detailed overview of exposure therapy, including its goals, how it works, and what can be expected. The idea of exposure therapy can be frightening, and this is a chance to put minds at ease.
• Development of a hierarchy: A series of anxiety-inducing experiences are created, and arranged from least anxiety-provoking to most. There need to be enough entries on the list to create a gradual increase in anxiety. Jumping from a little bit anxious to panic-inducing is not good for anyone!
• Exposure proper: This step involves exposing the person with SAD to the anxiety-provoking situations outlined in the hierarchical list, starting with the one that causes the least anxiety. Sometimes the therapist models the exposure and response before the person with SAD attempts it. Direct exposure is preferred, but not always feasible. If the exposure can’t happen in-person, imagery and virtual reality can be used.
• Generalization and maintenance: Homework time! In this stage, the therapist assigns activities to do at home to reinforce the skills learned in the therapy session, and repeat exposures in similar situations outside of the therapy office. Exposure outside of therapy removes the association of the office with successfully facing anxious situations.

Exposure therapy is considered successful once the person with SAD has worked through all of the situations on the list, and has reduced their anxiety to appropriate levels for their age and development.

Medications

While selective serotonin reuptake inhibitors (SSRIs) have been shown to be effective in treating SAD, due to the potential of side effects and the lack of availability for FDA approved SSRIs available for children under six, medication is rarely prescribed as the first-line treatment to children with SAD. It may be administered if first-line treatments such as CBT are not effective.

For adults, SSRIs may be prescribed on their own, but they are more effective as part of a combination therapy. Although this can vary, they are typically taken for six months then gradually tapered off.

Whether developmentally normal separation anxiety or SAD, separation can be hard on young children and their parents. To make the transition easier for young children, parents can:

• Make it a quick goodbye: Always say goodbye to your child before leaving. Sneaking away teaches children that you can disappear at any time without warning. But make those goodbyes quick, even if your child is upset. Staying longer reinforces the anxiety and its response, and coming and going again after you have left is confusing and disruptive. Say a quick goodbye and go – your child’s caregiver will thank you!
• Be consistent: Routines are comforting for all children, but particularly anxious ones. Try to keep your child’s drop off routine consistent and predictable. Your child will feel less anxious if they know what to expect.
• Follow through: If you make a promise to your child, keep it. Developing trust with your child helps them believe you when you say you are coming back.
• Use terms your child understands: Your child has no concept of time according to a clock. 5:00 means nothing to them, but “after snack time” does. If you will be away from your child for a number of days, use “sleeps” to indicate the amount of time you will be gone and when you will return.
• Practice: Leave your child for a short time with someone they know and trust, like Grandma. Leave the room for a few minutes during a playdate, letting your friend watch your child. Schedule an orientation with your child’s daycare before they start to become familiar with the new surroundings and to practice saying goodbye and coming back. Remember to say goodbye, even when it’s just for practice.

Having a healthy attachment with a parent or parents helps greatly when it comes to both separation anxiety and SAD. To encourage a secure attachment  from the start, foster a supportive, safe, and dependable environment for your baby or young child. Children who feel secure have an easier time exploring new places and experiences.

Object permanence is the beginning of preparing for time away from your child. You can help develop your child’s understanding and trust in object permanence by playing simple games.

• Play “leave and return”: Leave the room and come back. Talk to your child from another room, out of their sight. Seeing you regularly leaving and returning helps your child understand that you are not gone for good just because they can’t see you.
• Peek-a-boo: Cover your face, then uncover it, excitedly saying “peek-a-boo!”
• Hiding objects: Hide a toy under a blanket, ask your child where it is, then pull the blanket off to reveal the toy was under there the whole time. Try it again by hiding a toy somewhere else and finding it.

For adolescents and adults living with SAD, it may be helpful to follow coping strategies for anxiety.

• Social coping strategies: Participate in social activities, connect with family and friends, and ask for support when you need it or reach out to an anxiety support group.
• Emotional coping strategies: Practice mindfulness, learn your triggers, and practice acceptance.
• Physical coping strategies: Take care of your body by eating well, exercising, and getting enough sleep.

A Word From Verywell

If you are the parent of a baby or young child who is experiencing separation anxiety, try to remind yourself that while difficult, it is absolutely normal and developmentally appropriate. Like all difficult stages, this too shall pass.

If your older child or teen—or you—develop SAD, breathe easier knowing that help is available. With proper treatment, SAD can become a thing of the past.

If you or your child are struggling with SAD, contact the Substance Abuse and Mental Health Administration (SAMHSA) National Hotline for treatment and support group referrals at 1-800-662-HELP (4357).

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Silove DM, Marnane CL, Wagner R, Manicavasagar VL, Rees S. The prevalence and correlates of adult separation anxiety disorder in an anxiety clinic .  BMC Psychiatry . 2010;10(1):21. doi:10.1186/1471-244X-10-21

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By Heather Jones Jones is a freelance writer with a strong focus on health, parenting, disability, and feminism.

Home — Essay Samples — Nursing & Health — Anxiety — Overview of Stranger and Separation Anxiety

Overview of Stranger and Separation Anxiety

• Categories: Anxiety Anxiety Disorder

About this sample

Words: 1265 |

Published: Feb 8, 2022

Words: 1265 | Pages: 3 | 7 min read

Table of contents

Introduction, topic analysis, works cited.

• Feldman, R. S. (2017). Development across the lifespan. Pearson.
• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.
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• American Psychological Association. (n.d.). Separation anxiety disorder. In APA Dictionary of Psychology. Retrieved from https://dictionary.apa.org/separation-anxiety-disorder
• American Psychological Association. (n.d.). Stranger anxiety. In APA Dictionary of Psychology. Retrieved from https://dictionary.apa.org/stranger-anxiety
• Bowlby, J. (1969). Attachment and loss: Vol. 1. Attachment. Basic Books.
• Merikangas, K. R., He, J., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., ... & Swendsen, J. (2010). Lifetime prevalence of mental disorders in US adolescents: Results from the National Comorbidity Survey Replication-Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry, 49(10), 980-989.
• Copeland, W. E., Shanahan, L., Davisson, E. K., Navrady, L., & McLeod, S. D. (2020). Separation anxiety in childhood and adolescence: Clinical findings and implications for DSM-5. Depression and Anxiety, 37(1), 6-17.
• Pincus, D. B., May, J. E., Whitton, S. W., Mattis, S. G., Barlow, D. H., & Albano, A. M. (2010). Cognitive-behavioral treatment of panic disorder in adolescence. Journal of Clinical Child & Adolescent Psychology, 39(5), 638-649.
• Kim-Cohen, J., Caspi, A., Moffitt, T. E., Harrington, H., Milne, B. J., & Poulton, R. (2003). Prior juvenile diagnoses in adults with mental disorder: Developmental follow-back of a prospective-longitudinal cohort. Archives of General Psychiatry, 60(7), 709-717.

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Understanding Separation Anxiety Disorder: a Comprehensive Overview

This essay about Separation Anxiety Disorder (SAD) offers a comprehensive overview of a condition marked by excessive fear or anxiety over separation from attachment figures. It explains how SAD affects individuals across different life stages, causing significant distress and impairment in daily life. The essay outlines the symptoms, including emotional, physical, and behavioral signs, and discusses the importance of early childhood in the development of these attachment issues. It also covers the diagnostic criteria and treatment options for SAD, such as psychotherapy and family therapy, emphasizing the goal of helping individuals manage separation anxiety in a healthy way. The essay concludes by advocating for greater understanding and empathy towards those with SAD, highlighting the condition’s impact on individuals’ lives and the importance of supportive treatment in overcoming it. You can also find more related free essay samples at PapersOwl about Separation Anxiety Disorder.

How it works

Separation Anxiousness Syndrome (SAS) represents a psychological ailment often evoking imagery of a sorrowful child on their inaugural school day, clinging fervently to a parental limb, beseeching them to linger. Nonetheless, the expanse of this syndrome transcends the confines of the scholastic threshold, casting its shadow over individuals traversing diverse life epochs, ensnaring them in a grasp capable of profoundly derailing quotidian functionality. SAS is typified by an inordinate dread or angst regarding detachment from those with whom one shares a profound attachment, precipitating an array of emotional, physiological, and behavioral manifestations that can impede the pursuit of a conventional existence.

The genesis of SAS frequently traces back to nascent childhood, a pivotal epoch for attachment formation. The attachment theory, spearheaded by John Bowlby, posits that the affiliations fostered between a child and their caregiver constitute cardinal facets of the child’s evolution and welfare. For certain individuals, these attachment affiliations transmute into focal points of acute trepidation and anxiety upon the specter of separation. It’s a condition that murmurs forebodings of imminent calamity at the prospect of detachment, weaving a narrative of solitude and susceptibility that can prove paralyzing.

The exhibition of SAS exhibits a kaleidoscopic spectrum among individuals but shares a common thread of disproportionate apprehension pertaining to the prospect of losing attachment figures or the specter of harm befalling them. This apprehension can incite physiological manifestations such as cephalalgia, gastric discomfort, and emesis, alongside emotional and behavioral indicants like somnambulistic episodes, refusal to attend educational institutions, or disproportionate distress preceding separation from a cherished individual. In the case of adults, SAS can metamorphose into an overwhelming dread of parting from progeny, partners, or other intimate associations, frequently culminating in challenges sustaining employment or participating in communal activities owing to an incapacity to endure separation from loved ones.

The diagnosis of SAS necessitates a meticulous evaluation of these symptomatic presentations and their ramifications on an individual’s operational capability. Mental health practitioners scrutinize indicators that the anxiety exceeds the developmental threshold of the individual and that it substantially encumbers their capacity to engage in routine activities. It’s a delicate equilibrium to strike, delineating between the customary ebb and flow of attachment and the enduring, acute trepidation emblematic of SAS.

Therapeutic modalities for SAS commonly encompass a blend of psychotherapeutic interventions, family-based therapeutic approaches, and, in select instances, pharmacotherapy. Cognitive-behavioral therapy (CBT) emerges as a prevalent modality, aimed at facilitating individuals in comprehending and managing their fears by incrementally exposing them to the concept of separation within a regulated and supportive milieu. Family therapy assumes pivotal significance as it addresses familial dynamics that may precipitate or exacerbate the syndrome, fostering healthier attachment dynamics.

The trajectory to surmounting SAS is devoid of linearity. It necessitates patience, empathy, and an individualized approach cognizant of the idiosyncratic requisites of the afflicted individual. The objective of intervention is not to sever the bonds of attachment but to fortify the individual’s resilience in contending with separation in a salubrious manner. It’s an endeavor aimed at fostering fortitude, nurturing autonomy, and reshaping the narrative of trepidation into one underscored by confidence and assurance.

In a societal milieu oft fraught with stigmatization of mental health maladies, comprehension and compassion vis-à-vis conditions such as SAS assume paramount import. It serves as a poignant reminder that the anxieties and trepidations we grapple with, albeit imperceptible to the unaided gaze, wield an impact as tangible and profound as any corporeal affliction. By illuminating the contours of SAS, we catalyze a discourse that may engender enhanced support, intervention, and ultimately, a milieu characterized by heightened empathy toward the afflicted.

In summation, Separation Anxiousness Syndrome epitomizes a convoluted ailment that encapsulates the profound apprehensions of loss and desertion inherent to the human condition. Nonetheless, with the requisite support and intervention, individuals afflicted with SAS can traverse these trepidations and navigate toward lives replete with fulfillment. It stands as a testament to the indomitable resilience of the human spirit and the potency of human connection, underscoring the verity that even amid our most vulnerable moments, we are not bereft of companionship.

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• Patient Care & Health Information
• Diseases & Conditions
• Separation anxiety disorder

Diagnosis of separation anxiety disorder involves figuring out whether your child is going through a typical stage of development or if the symptoms are serious enough to be considered separation anxiety disorder. After ruling out any medical conditions, your child's pediatrician may refer you to a mental health professional with expertise in anxiety disorders in children.

To help diagnose separation anxiety disorder, a mental health professional will likely talk with you and your child, usually together and also separately. Sometimes called a psychological evaluation, a structured interview involves talking about thoughts and feelings and behavior.

Separation anxiety disorder is usually treated first with psychotherapy. Sometimes medicine also is used if therapy alone isn't working. Psychotherapy involves working with a trained therapist to lessen separation anxiety symptoms.

• Psychotherapy

Cognitive behavioral therapy (CBT) is an effective form of therapy for separation anxiety disorder. Exposure treatment, a part of CBT , has been found to be helpful for separation anxiety. During this type of treatment your child can learn how to face and manage fears about separation and uncertainty. Also, parents can learn how to effectively give emotional support and encourage independence that suits the child's age.

Sometimes, combining medicine with CBT may be helpful if anxiety symptoms are severe and a child isn't making progress in therapy alone. Antidepressants called selective serotonin reuptake inhibitors (SSRIs) may be an option for older children and adults.

More Information

• Cognitive behavioral therapy

Lifestyle and home remedies

While separation anxiety disorder gets better with professional treatment, you also can take these steps to help ease your child's separation anxiety:

• Learn about your child's separation anxiety disorder. Talk to your child's mental health professional to learn about the condition and help your child understand it.
• Follow the treatment plan. Keep the therapy appointments for your child. Consistency makes a big difference.
• Take action. Learn what triggers your child's anxiety. Practice the skills learned from the mental health professional so you're ready to deal with your child's anxious feelings during separations.

Coping and support

Coping with a child who has separation anxiety disorder can be frustrating and cause conflict with family members. It also can cause a great deal of worry and anxiety for parents.

Ask your child's therapist for advice on coping and support. For example, the therapist may suggest you:

• Show calm support. Encourage your child to try new experiences, experience separation and develop independence with your support. Model bravery when facing your own distress to help when your child is facing fears.
• Practice goodbyes. Leave your child with a trusted caregiver for short periods of time to help your child learn that you will return.

It's also important to have supportive relationships for yourself, so you can better help your child.

Preparing for your appointment

If you think your child may have separation anxiety disorder, start by seeing your child's pediatrician. The pediatrician may refer you to a mental health professional with expertise in anxiety disorders.

What you can do

Before your appointment, make a list of:

• Your child's symptoms. Note when they occur, whether anything seems to make them better or worse, and how much they affect day-to-day activities and interactions.
• What causes your child to be anxious. Include any major life changes or stressful events your child dealt with recently, as well as any past traumatic experiences.
• Any family history of mental health problems. Note if you, your spouse, your parents, grandparents, siblings or your other children have struggled with any mental health problems.
• Any health problems your child has. Include both physical health conditions and mental health problems.
• All medicines that your child takes. Also include any vitamins, herbs or other supplements, and the doses.
• Questions to ask the healthcare professional or mental health professional.

Questions to ask may include:

• What do you think is causing or worsening the anxiety?
• Are any tests needed?
• What type of therapy might help?
• Would medicine help? If so, is there a generic option?
• Besides professional treatment, are there any steps I can take at home that might help?
• Do you have any materials that can help me learn more? What websites do you suggest?

Feel free to ask other questions during the appointment.

What to expect from your doctor

The mental health professional is likely to ask you questions. For example:

• What are your child's symptoms, and how severe are they? How do they affect your child's ability to do daily activities?
• When did you first begin noticing your child's separation anxiety?
• How do you respond to your child's anxiety?
• What, if anything, seems to make your child's anxiety worse? What makes it better?
• Has your child had any traumatic experiences recently or in the past?
• What, if any, physical or mental health conditions does your child have?
• Does your child take any medicines?
• Do you or any of your blood relatives have ongoing anxiety or other mental health conditions, such as depression?

Be ready to answer questions so that you have time to talk about what's most important to you.

• Separation anxiety disorder. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5-TR. 5th ed. American Psychiatric Association; 2022. https://dsm.psychiatryonline.org. Accessed April 11, 2024.
• Patel AK, et al. Separation anxiety disorder. JAMA. 2021; doi:10.1001/jama/2021.17269.
• Mohammadi MR, et al. Prevalence, comorbidity and predictor of separation anxiety disorder in children and adolescents. Psychiatric Quarterly. 2020; doi:10.1007/s11126-020-09778-7.
• Separation anxiety disorder. Merck Manual Professional Version. https://www.merckmanuals.com/professional/pediatrics/psychiatric-disorders-in-children-and-adolescents/separation-anxiety-disorder. Accessed April 11, 2024.
• Anxiety and children. American Academy of Child and Adolescent Psychiatry. https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/The-Anxious-Child-047.aspx. Accessed April 11, 2024.
• Alvarez E, et al. Psychotherapy for anxiety disorders in children and adolescents. https://www.uptodate.com/contents/search. Accessed April 11, 2024.
• Glazier Leonte K, et al. Pharmacotherapy for anxiety disorders in children and adolescents. https://www.uptodate.com/contents/search. Accessed April 11, 2024.
• LeBow JR (expert opinion). Mayo Clinic. April 26, 2024.

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