By Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S
Separation anxiety is a normal stage of development found in infants and toddlers. Many young children experience a certain period of separation anxiety. It commonly occurs in babies between 8-12 months of age. Most children outgrow separation anxiety by about 2-3 years of age i.e. it usually disappears around this age.
Separation anxiety is a sign of a more serious condition in some children known as separation anxiety disorder or SAD. It would start as early as in preschool or during teenage years. About 3-4% children have this condition. A child should have symptoms of SAD for at least 4 weeks for the problem to be diagnosed as SAD.
It is an indicator of general mood and mental health issues. About 1/3 children with this disorder will be diagnosed with mental illness when they grow up into adults.
The separation anxiety of the child should be considered to have shaped into separation anxiety disorder if the separation anxiety –
Is intense or prolonged
Interferes with school or other daily activities of the child
Includes panic attacks or other problems
Most often than not this disorder relates to the child’s anxiety about parents. It could also relate to other caregivers who are close to the child. Separation anxiety disorder can also occur in teenagers and adults but is less often than in children. When it does, it causes significant problems wherein they would find it difficult to leave home or go to work. The symptoms would ease with treatment.
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Table of Contents
It is caused by a combination of biological and environmental factors. The child may inherit a tendency to be anxious. Imbalance of brain chemicals – norepinephrine and serotonin play a part in causation of this disorder. Anxiety and fear may also be learnt from family members or others. SAD may also be caused by a traumatic event.
This condition equally occurs in boys and girls. Children with parents having anxiety disorder are more prone to have SAD.
When the symptoms of ‘separation anxiety’ are excessive for the developmental age of the child and also cause significant distress in daily functioning, the given condition will be diagnosed as Separation Anxiety Disorder.
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Distress – which is recurrent and excessive, the distress is about anticipating or being away from home or loved ones
which is constant and excessive,
is about losing a parent or any other loved one to a disaster or illness
that something bad is about to happen (being kidnapped or lost leading to separation from parents / loved ones)
Refuse – the child would refuse to be away from home since there is always a fear of separation from parents / loved ones
Fear of being alone – the child doesn’t want to be all alone at home without the company of a parent / loved ones
Refuse – to sleep away from home without a parent or loved ones in and around
Nightmares – the child would get repeated nightmares about getting separated from parents and loved ones
Frequent complaints – in anticipation of getting separated from a parent or other loved one the child would frequently complain about headaches, stomach aches and other symptoms.
Separation anxiety disorder may be associated with panic disorder and panic attacks.
The first symptoms often appear when the child is in 3rd or 4th grade. The symptoms may also occur after a break from school i.e. during holidays, summer or following a long term sickness. Each child would have a different set of symptoms.
Symptoms manifest when the child gets separated from parents or caregivers. Anxiety related behaviors also occur with fear of separation.
Common behaviors of the child with SAD are –
Child clings on to the parents
Being clingy even when at home
Worry when parted from home / family, about the safety of a family member/ sleeping away from home
Worry about safety of self
Refusal to do things that might cause separation
Emotional / temper tantrums
Child refuses to go to school
Poor performance at school
Child doesn’t interact with other children in a healthy way
Fearful / reluctant to be alone
Refusing to sleep alone
Have repeated nightmares of getting separated
Physical illness such as headaches or vomiting
Muscle aches / tension
Frequent stomach ache, headache and other physical symptoms
Panic / temper tantrums at times of separation from parents / caregivers
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SAD is usually diagnosed by a child psychiatrist or mental health expert after a thorough mental health evaluation of the child. The child’s worry or fear about being away from family members must last for at least 4 weeks for a diagnosis of SAD to be made.
Diagnosis mainly includes determining if the anxiety is a part of normal stage of development or if it has matured to become a disorder. After conducting essential tests and ruling out medical conditions the physician would either be able to diagnose SAD or may even refer the child to a psychologist or child psychiatrist. A psychological evaluation, structured interview conducted by a child psychologist and behavior observance will all help in diagnosing this condition. We need to remember that this disorder might occur along with other mental health problems.
Usually, SAD doesn’t go away without treatment. If untreated, it can lead to panic disorder and other anxiety disorders as the child enters adulthood.
Anytime is the right time to see the doctor provided you have observed signs of separation anxiety in your child which is blown out of proportions. The sooner you see the doctor and seek help the better it is for your child. Talk openly about your child’s problem to your pediatrician, healthcare provider or child psychiatrist.
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Stressful life events resulting in separation like –
Illness or death of a loved one / family member
Parents going into divorce
Loss of beloved pet
Going away to school by moving away from home (leaving parents behind) / changing schools
Moving to new home
SAD is more likely to occur in children with –
Family history of depression or anxiety
Having blood relatives having anxiety related disorders
Temperaments – People with certain temperaments are more prone to anxiety disorders than what others are. Shy and timid personalities are more prone to get this disorder.
Environmental issues – experiencing some type of disaster that involves separation
Low socioeconomic status
Problems dealing with kids of their own age
Deficit and inappropriate parental interaction
Other anxiety disorders – generalized anxiety disorders, phobias, panic attacks, social anxiety disorder, agoraphobia etc
OCD – obsessive compulsive disorder
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Effects of SAD on family life
SAD seriously affects not only personal and emotional life but also emotional and social development of individuals. The child may avoid those experiences which are very important for normal development.
The disease also can extend to affect family life. Some problems related to family life caused by SAD are –
Family activities limited by negative behavior
Parents of these children might not find time for each other or even for themselves as they are totally focusing on their child’s problems, this leads to frustration and disturbance in relationships since caretaking becomes very much absorbing
Siblings of child with SAD become jealous because that child is getting all care and extra attention from parents, they will feel let down and less taken care of
If your child has SAD you need to speak openly to your doctor about getting the best treatment options as possible and to find ways you can help to manage the effect it is imparting and hence affecting on family life.
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Sure preventive measures for SAD in children and teens are not known even to experts.
Take advice and seek help as soon as possible – If you notice signs of SAD in your child you need to seek medical evaluation as soon as possible.
Early diagnosis and treatment is the key – Early diagnosis and treatment will help in reducing symptoms and prevent worsening of disorder. Prompt treatment would also enhance your child’s normal development. It can also improve the child’s quality of life.
Stick to the plan – Sticking to the plan of treatment and promptly following every bit of it would prevent relapses or worsening of symptoms.
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Lifestyle and home remedies are not alternative to professional treatment of SAD but they might help in easing the symptoms to an extent. The below mentioned may be considered –
Know and learn – Explore and learn about your child’s SAD and understand the symptoms. To do this talk to the mental health professional who is helping out with your child. With this you might understand your child’s disorder and also help your child to understand and cope up with SAD and its symptoms.
Stick to the treatment plan – Be consistent with making and following up appointments for your child with a child psychiatrist and stick to the treatment plan once it has been designed.
Take prompt action – Learn about the triggers which worsen anxiety episodes in your child. Practice and get thorough with all the strategies that you have worked out and charted out with the help of your mental health professional. This will make and keep you ready to deal with your child’s anxious feelings during separations. Be ready to take action and help your child anytime.
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Treatment of SAD will depend on the symptoms, age and general health of the child. It will also depend on how severe the condition is.
SAD is usually treated with psychotherapy (psychological counseling / talk therapy) along with medication. This involves working with a therapist to reduce the symptoms of the disease.
The below mentioned interventional methods are administered either singly or in combination.
CBT (Cognitive Behavioral Therapy) – is an effective form of psychotherapy for SAD. This will help your child learn how to face and manage fears about separation and also to handle his or her anxiety. Parents too can learn methods of providing emotional support and encourage age appropriate independence. Common techniques include deep breathing and relaxation.
Medicines – anti-depressant or anti-anxiety medicines will be administered.
CBT + Medication – Sometimes a combo of CBT and medication may be helpful if symptoms are severe. Antidepressants, mainly SSRIs, may be an option for older children and adults.
Family therapy – parents play an important role in any treatment.
School input and environment – the involvement of the school in curing this condition is also vital. School should also provide an ideal healing environment for the child. The teachers shall encourage the child to interact with other classmates. As a parent you can speak your concerns about your child’s classroom with the teacher, principal or guidance counselor and request them to provide a friendly environment for your child.
Parent-child interaction therapy – This is carried out in 3 main treatment phases –
CDI (Child Directed Interaction) – This focuses on improving the quality of relationship between parents and their child. It involves providing love, attention, praise and warmth to the child. The child will start feeling safe with this therapy.
BDI (Bravery Directed Interaction) – This educates parents about the reasons for their child’s anxiety. A bravery ladder is developed by your child’s therapist. This ladder displays situations that cause anxious feelings. It establishes rewards for positive reactions.
PDI (Parent Directed Interaction) – This teaches parents to communicate clearly with their child which in turn helps in managing poor behavior.
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Help from parents
Parents have an important and crucial role to help their children fight out the separation anxiety disorder. As a parent one can do the below mentioned –
Keep in touch with the doctor / healthcare provider / psychiatrist (child) and keep updating everything about your child to get timely help
Keep all appointments with the doctor updated and follow instructions
Assure, speak to and support your child
Give independence to the child to explore self and the surroundings in accordance with the age of your child
Identify the ‘stressful situations’ for your child, this will help you to prepare your child to confront those situations and deal with them as a team
Discuss your child’s SAD with his or her school authorities, let them know what the child is undergoing and help him or her in the best possible way. This will help the teachers to provide extra reassurance and support your child in certain situations.
Take help and support from local community services or online services. You can learn and interchange strategies of handling SAD in your child by keeping in touch with parents who have children suffering from similar conditions.
Leave your child with a trusted caregiver for short periods of time and help your child to learn that they can cope up with this separation and can be okay till you return back
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SAD is a disease of childhood but can also be seen in adults. Adults with separate anxiety would have extreme fear that their family members or loved ones will face bad things or events in their life. It is associated and coexists with other anxiety related conditions such as panic disorder, generalized anxiety disorder and agoraphobia.
As we already know if the symptoms of separation anxiety continue into late childhood the child will be diagnosed as having SAD. This can be considered as ‘child separation anxiety disorder’. If the same disorder continues into adulthood it will be diagnosed as ‘adult separation anxiety disorder’. The symptoms in children and adults are almost similar.
In adult type of the disease people feel anxious being away from children or spouses. There will be impairment at work places and also to combat other responsibilities.
High levels of anxiety and panic attacks when the loved ones are far away or beyond reach
Extreme levels of sadness
Difficulty in concentrating
Strict and over involved parenting
Being an overbearing partner
Extreme fear that you or your loved ones may be abducted or fatally injured
One would hesitate or refuse persistently to leave their loved ones and go away for even a short period of time
One would feel it difficult to sleep away from a loved one because they have a fear that something bad will happen to them
Depression / anxiety attacks (related to the same things explained above)
Pains, headaches, diarrhea etc
Symptoms must impair functioning of an individual for at least a time period of 6 months for a diagnosis of adult separation anxiety disorder to be made.
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Loss of loved ones
Significant event (moving out to college or out of home)
Those who were diagnosed with separation anxiety disorder in childhood
Adults who grew up with overbearing parents
Those who are suffering from one or more of generalized anxiety disorder, PTSD (post traumatic stress disorder), panic disorder, social anxiety disorder or personality disorders)
Total mental and physical examination and evaluation conducted on you by your doctor will help in diagnosis of SAD in adults. The criteria outlined in DSM-V are used for making the diagnosis. According to these criteria
One should have excessive fear or anxiety about being separated from people you are close to (both your anxiety and fear has to be inappropriate developmentally)
Symptoms must be present for a minimum period of 6 months
Symptoms are too severe and they affect one’s social functioning and responsibilities
Symptoms of this disorder cannot be better explained by a different disorder (this would rule out other health problems)
The treatment for adult type SAD will be similar to treatments used for other anxiety disorders. The best possible treatments for this condition includes one or more of the below mentioned –
CBT – cognitive behavioral therapy
DBT – dialectical behavioral therapy
Medications – such as antidepressants
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Adult separation anxiety will generally have its onset in childhood or adulthood. It can affect your quality of life just like other anxiety disorders do. You need to talk to a medical professional or a psychiatrist if you suspect you have symptoms of separation anxiety disorder. Earlier interventions will help in relieving symptoms.
A study showed that childhood separation anxiety disorder may be a risk factor for multiple anxiety syndromes in adulthood.
Another study showed that heightened early separation anxiety is specifically associated with risk of adult panic disorder with hereditary factors underlying that cluster of anxiety disorders.
Yet another study has been made in relation to genetic and environmental contributions to separation anxiety.
In a study ‘Subpopulations of early separation anxiety – relevance to risk of adult anxiety disorders’ – it was shown that only a sub-population of anxiety sufferers may have elevated levels of Separation Anxiety. Identification of this group may be important for early detection and intervention.
Study – Separation anxiety disorder in childhood is a risk factor for future mental illness.
In a study made on ‘frequency and clinical correlates of adult separation anxiety in a sample of 508 outpatients with mood and anxiety disorders’ it was found that adult separation anxiety disorder is likely to be much more common in adults than previously recognized. Research is needed to better understand the relationships of this condition with other co-occurring affective disorders.
Clinical correlates and significance of separation anxiety in patients with bipolar disorders – Another study explored the frequency and severity of Separation Anxiety symptoms during childhood and adulthood in a sample of bipolar patients in comparison to subjects with other anxiety and mood disorders.
All anxiety disorders are studied in comparison to ‘Chittodvega’ explained by Master Charaka as one of the diseases caused by imbalance of rajas and tamas qualities of mind. Since separation anxiety disorder is also a type of anxiety disorder it falls under the bracket of chittodvega. Separation Anxiety Disorder is treated on the lines of treating chittodvega.
Other principles of treating SAD –
on the lines of ‘treatment of contamination of mind carrying channels’
treatment of unmada and apasmara disorders
treatment of vata disorders
treatment of manasika rogas (mind disorders)
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