Separation Anxiety Disorder Assessment and Treatment
A variety of factors likely contribute to the development of Separation Anxiety Disorder, as is also the case for Anxiety Disorders. Children may inherit a tendency to develop anxiety disorders, typically described as a personality trait called Neuroticism or Emotional Stability, from their parents. Temperamental factors like neuroticism may be triggered by severely stressful life events such as child abuse, the loss of parents, institutionalization (e.g., being placed into an orphanage, or into foster care), or even less stressful but still difficult life events such as a family death or moving to a new house. Neurotic tendencies that are triggered by stressful events may precipitate the development of the disorder.
According to the DSM, approximately 4% of children qualify for a diagnosis of Separation Anxiety Disorder, making it a rather common problem. Younger children are more prone to develop the problem than are older children and adolescents.
Children tend to grow out of Separation Anxiety Disorder as they mature. However, in some cases, they go on to develop new, related disorders. One longitudinal (following children's progress over time) study found that over 90% of children previously diagnosed with Separation Anxiety Disorder no longer met full criteria for that disorder by adolescence. Unfortunately, about 25% of those children appeared to have "traded in" their separation anxiety for a depressive disorder! As depression and anxiety are related conditions known to be influenced by the personality or temperament trait known as Neuroticism, this is not an entirely surprising finding .
Retrospective studies (looking at factors that occurred in the past) suggest that up to 50% of adults with Anxiety Disorders had Separation Anxiety Disorder during their childhood. Many professionals interpret this finding to mean that Separation Anxiety Disorder might function as a childhood precursor to adult anxiety disorders. Acting on this interpretation, some professionals stress the importance of treating Separation Anxiety while children are still young, so as to possibly prevent or decrease the severity of future anxiety problems.
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Assessment of Separation Anxiety Disorder
Children suspected of having Separation Anxiety Disorder should be assessed by a mental health clinician with expertise in working with children with anxiety disorders. During the assessment process, children will likely be interviewed, possibly with a structured interview such as the Diagnostic Interview for Children and Adolescents . Children may also be asked to complete various self-report questionnaires, such as the Social Phobia and Anxiety Inventory (previously described in our discussion of Selective Mutism, (click here to return to that section), or the Social Anxiety Scale, which screens for various aspects of social anxiety such as fear of negative evaluation, social avoidance, and distress. Caregivers may also be asked to participate in an interview process and to complete questionnaires, such as the Child Behavior Checklist .
Treatment of Separation Anxiety Disorder
Behavioral and Cognitive-Behavioral therapies tend to be the most effective methods for treating separation anxiety.
Systematic Desensitization and Flooding are two behavioral techniques that are useful for treating anxiety problems like Separation Anxiety Disorder. Both techniques are varieties of exposure therapy. All exposure therapies work on the same principle, derived from learning theory, known as habituation. The idea is that anxiety is increased when people successfully avoid things they fear, because they have learned that the avoiding the object or situation is a great way to keep from feeling unpleasant anxiety feelings. On the other hand, anxiety is decreased when people cease to avoid what they fear and learn that the object of their fears is not actually dangerous.
Simply forcing a person to confront and remain in the presence of feared things (called exposure) is the best way to treat anxiety. However, as you might imagine, it is difficult to get people to agree to engage in this type of procedure. A Systematic Desensitization technique avoids overwhelming anxious people by first teaching them relaxation methods to help them cope with their anxiety sensations, and then very gradually exposing them to progressively more intense images of situations they fear (or progressively more intense actual experiences). Eventually, people habituate (get used to, and less anxious in the presence of anxiety-provoking situations) over time in a more gentle fashion.
The list of progressively more intense situations used in systematic desensitization (called a hierarchy) is collaboratively produced by the therapist and the anxious child. For example, a less intense but still anxiety-provoking situation that children with Separation Anxiety Disorder might confront is being separated from their parent for 10 minutes while in their familiar house. A more intense situation might consist of being separated from their parent for a longer period while away from the home in an unfamiliar environment (such as a shopping center).
The Flooding technique is not nearly so gentle as systematic desensitization but it has the virtue of taking less time to implement. In this procedure, a therapist provides the anxious child with a sudden, intense exposure to a feared situation. No hierarchy or buildup occurs; the child is hit with the full fear all at once. Faced with imagining (or actually acting out) this feared scenario, children are initially very anxious, but eventually habituate and calm down, having survived an experience of intense fear and living through it. The now calm children see (and have learned) that nothing bad has happened to them despite their fears. They have also learned that they can be calm even when faced with their most feared situation.
Importantly, flooding is not forced upon children. It is only used with children who are old enough to give meaningful consent. In addition, children are strongly encouraged to stay and tolerate their feared situation, but children who attempt to flee are not prevented from doing so. Should a child flee, the therapist would discuss the escape attempt with the child and encourage the child to try it again a second time.
Cognitive-behavioral techniques used to treat Separation Anxiety focus on anxious children's thought habits that lead them to become anxious in the first place. Children may have unrealistic and exaggerated ideas about how dangerous it is to be alone, or fail to differentiate between past losses and present circumstances. For example, an anxious child may think that because she lost her mother to illness several years ago, that her father will also die. A cognitive therapist helps children to become aware of and to examine their thoughts and beliefs to see if they make logical sense. A child who is worried that her father might die because her mother died previously might be encouraged to make logical connections between the cause of her mother's death by an illness and father's lack of any similar illness. To make this point, the therapist might ask the child questions, like, "Is your father sick? Will he be participating in a particularly dangerous activity like sky-diving while he goes out to dinner tonight?" In answering these questions, the anxious child is helped to realize that the actual risk of her father dying is lower than she previously thought.
Medications are also used to treat Separation Anxiety Disorder. Both antidepressants (e.g., Clomipramine or Imipramine) and anxiolytic medications (anxiety reducing medications such as Buspirone) have been used with success. Various side effects can occur with the use of medications, including dry mouth, dizziness, seizures, aggressive behaviors, drowsiness, etc. As mentioned several times in this article, antidepressants have a "black box" warning because studies have shown that these medications can increase suicidal thoughts and behaviors in a small number of children. Children who are using these medications should meet regularly with a mental health therapist so that they can be closely monitored for suicidal thoughts and behaviors.