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Anxiety: Behavioral and Cognitive Strategies for Treating Anxiety - 10 CEUs

Section 26
Separation Anxiety

CEU Question 26 | CE Test | Table of Contents | Anxiety
Counselor CEUs, Psychologist CEs, Social Worker CEUs, MFT CEUs

Young children hate to be separated from their parents. These fears appear toward the end of the first year, when they begin to sense that their parents will not always be with them and give signs of discomfort in the presence of people they don’t know well. This normal separation anxiety peaks around age 2 and persists, slowly diminishing, through age 6 or 7.  If the fear of being apart from parents lasts for more than a month or persists in an older child and creates serious problems for the child or the family, it’s called separation anxiety disorder. Fortunately, good treatments are available, and most families don’t have to suffer long.

Children with separation anxiety disorder may be afraid to sleep at a friend’s house or even stay at a daycare center or attend a birthday party. They have nightmares about separation and may try to climb into bed with their parents at night. They may express fears that if they are apart, their parents will die by accident, illness, or crime, or they themselves will be lost or kidnapped. Threatened with separation, they cry, cling to their parents, throw tantrums, and develop physical symptoms—headaches, stomachaches, and sore throats.

Separation anxiety disorder is oft en first diagnosed at age 6 or 7, when a child goes to school.  Some children develop the disorder around age 12, on moving from elementary to middle school. The problem is more common in girls, and it is associated with depression and other anxiety disorders, especially social anxiety (incapacitating shyness) and panic disorder. A recent national survey found a lifetime rate of 4%.

Anxiety disorders run in families, and twin and adoption studies show that heredity is a factor in separation anxiety disorder.  Some children, probably for genetic reasons, are "behaviorally inhibited." Even at the age of four months, their hearts beat faster, and they shrink back when they encounter strangers. These children are most likely to suffer from separation anxiety disorder as they grow older. Events and circumstances can bring on the symptoms—especially big changes like moving to a new neighborhood, the appearance of a new baby, or a death in the family.

Attachment and separation
Much also depends on the quality of affection, support, and discipline that parents provide. The theories about attachment developed by the psychiatrist John Bowlby are oft en used to explain separation anxiety disorder. According to attachment theory, children have to be near their parents for biologically necessary comfort and support.  Secure attachment—knowing that the parent will be available, physically and emotionally—provides the child with a safe place to retreat to, a base from which to explore the world, and eventually a model for other relationships. As the child grows older and requires more independence, there is some resistance to separation on both sides, but if the attachment is secure, the process goes smoothly.

Children who are insecurely attached— lacking this confidence in their parents—are more likely to develop anxiety disorders, especially separation anxiety. And parents who are anxious and depressed themselves, or failing in other ways, promote insecure attachment.  Some parents are overprotective, reluctant to permit a degree of independence appropriate to the child’s age.  Others—people who are abusive, neglectful, or alternating unpredictably between affection and rejection—have not responded consistently to the child’s distress signals. Some simply don’t know how to provide the extra encouragement and special coaching that a timid child may need. Then the child may be afraid to tear himself away, fearing abandonment or exaggerating the dangers in the world outside the family.

Adult separation anxiety

Most grow out of it, but not all. Some recent studies suggest that a form of separation anxiety, although no longer directed at parents, can persist in adults or even begin in adulthood. A national survey found that 2% of the American adult population had suffered from separation anxiety in the previous year. The survey researchers estimate that in a third of cases childhood separation anxiety persisted, and in other cases it appeared in the late teens or early 20s.

Adolescents and adults with separation anxiety may worry about leaving someone close or going away on a trip.  They may be anxious when unable to speak to someone close regularly on the telephone. They may fret about events that might separate them from people close to them; have nightmares about being away from home; find it difficult to sleep alone; and even develop physical symptoms before going to work. These symptoms overlap with other anxiety disorders, especially panic disorder and agoraphobia.

In both children and adults, traumatic or complicated grief is related to separation anxiety. The symptoms of this disorder include obsessive yearning after the dead person, imagining that he or she is alive or feeling his or her presence, ruminating about the events preceding the death, and blaming oneself or others for the death. Complicated grief is a greater risk for a person who has always been anxious about parting.

Help in negotiating separation
The most widely used treatments for separation anxiety disorder are behavioral and cognitive therapies. Exposure therapy gradually accommodates a child to increased distance from parents or other caregivers. Cognitive therapy can teach the child to recognize and resist unrealistic fears.  Relaxation training may help with physical symptoms of anxiety. Contingency management—rewards, praise, and occasionally loss of privileges—is sometimes effective.

Parents can be educated about the problem and instructed on how to facilitate therapy, for example, by rewarding the child for overcoming fears. If family troubles are a source of the anxiety or the child is emulating an anxious parent, joint family therapy including the child may help. Studies have found that both individual and group cognitive behavioral therapy are effective, as is added parental involvement.

No drugs are approved for separation anxiety in children. Selective serotonin reuptake inhibitors (Prozac and its cousins), the standard drug treatment for adult anxiety disorder, may be helpful, but little is known about their long-term risks and benefits in children. Physicians have become more reluctant to prescribe antidepressants for children because of concerns about the drugs’ potential for causing suicidal thoughts and behavior. An antidepressant may help if the child with separation anxiety is also depressed.

Symptoms of childhood separation anxiety disorder
Starting before age 18, three of the following:
1. Excessive distress about actual or anticipated separation from home or parents.
2. Persistent concern about losing parents or about some harm coming to them if the child is not with them.
3. Persistent fear of being lost or kidnapped when separated from parents.
4. Persistent reluctance to go to school because of fear of separation.
5. Persistent reluctance to be alone—with or without parents at home or significant adults in other places.
6. Persistent reluctance to sleep away from home or go to sleep without a parent nearby.
7. Repeated nightmares about separation from parents.
8. Repeated complaints of headaches and other physical symptoms when anticipating separation from parents.

Adapted from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, 2000.
- Harvard Health Publishing. (2007, January). Separation anxiety. Retrieved from https://www.health.harvard.edu/newsletter_article/Separation_anxiety
The box directly below contains references for the above article.


Separation Anxiety Disorder in Childhood as a Risk Factor for Future Mental Illness

- Lewinsohn, P. M., Holm-Denoma, J. M., Small, J. W., Seeley, J. R., & Joiner, T. E. (2008). Separation Anxiety Disorder in Childhood as a Risk Factor for Future Mental Illness. Journal of the American Academy of Child & Adolescent Psychiatry, 47(5), 548-555. doi:10.1097/chi.0b013e31816765e7

Personal Reflection Exercise #12
The preceding section contained information about separation anxiety.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Finsaas, M. C., & Klein, D. N. (2021). Adult separation anxiety: Personality characteristics of a neglected clinical syndrome. Journal of Abnormal Psychology, 130(6), 620–626.

Finsaas, M. C., Olino, T. M., Hawes, M., Mackin, D. M., & Klein, D. N. (2020). Psychometric analysis of the adult separation anxiety symptom questionnaire: Item functioning and invariance across gender and time. Psychological Assessment, 32(6), 582–593.

Zhou, S., & Li, X. (2021). Maternal and paternal worry, anxious rearing behaviors, and child anxiety during the preschool years. Journal of Family Psychology. Advance online publication.

Online Continuing Education QUESTION 26
Under what circumstances is separation anxiety relabeled separation anxiety disorder? Record the letter of the correct answer the CE Test.

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