Separation Anxiety and Separation Anxiety Disorder, also known as SAD, are an acute distress that first occurs in children beginning in the first six to eight months of life (Weiten, 2005). Usually a parent will begin to notice changes in their infant when a usually confident child will show signs of distress when separated from an attachment figure, such as their mother or caregiver (Oltmanns, & Emery, 2010). Normal separation anxiety will exhibit crying and clinging if an attachment figure even leaves for a brief moment, but this anxiety usually peaks around fourteen to eighteen months of age, and then will decline (Weiten, 2005). However, SAD is a "persistent and excessive worry," where symptoms have a much great range, which include "worry for the safety of an attachment figure, fears of getting lost or being kidnapped, nightmares with separation themes, and refusal to be alone." (Oltmanns, & Emery, 2010) Other symptoms may be physical, such as headaches, stomachaches, nausea, heart palpitations, dizziness, and/or panic attacks, tantrums, screaming and pleading (Doobay, 2008). For a child to be properly diagnosed with SAD they must exhibit three or more of the above mentioned symptoms for at least four weeks (Oltmanns, & Emery, 2010). One of the major issues with SAD in children is that School Refusal is often accompanied by the anxiety, which is a school phobia, or a severe unwillingness to attend school, and is often preceded by stomachaches and headaches (Oltmanns, & Emery, 2010).
There are several theories as to the underlying causes of separation anxiety and SAD. One of the main theories to SAD in children has to do with attachment styles, thinking along the lines that a securely attached child will successfully make it past the fourteen to eighteen month period of expected anxiety and grow up to be a secure, confident adult (Weiten, 2005). Whereas anxious-ambivalent attached children are at the highest risk for developing SAD because they are already distressed when separation from their attachment figure as it is (Weiten, 2005). Some psychologists have used twin studies to examine the effects of genetics and environmental roles in the causes of SAD, with consistent results for environment and inconsistent results for genetics (Feigon, Waldman, Levy, & Hay, 2001). Recently there has been a rise in the number of young adults and adults who have reported symptoms of SAD, especially in college age freshman, and the reasons and underlying symptoms for these adults is unknown at this time due to the Diagnostic Statistical Manual only recognizing SAD if it has occurred previously to the age of eighteen, which is not always the case for these adults (Seligman, & Wuyek, 2007). The most obvious way to prevent any separation anxiety disorder among children is to make sure they securely attach to their parents or caregiver. This means that a child must feel that their needs are being met in a consistent and responsive manner, and that caregivers interact with their children on a regular basis (Weiten, 2005). However, for adults who have no recollection of separation anxiety as children, where the disorder has suddenly appeared in adulthood, answers for prevention may be found in other comorbid disorders such as depression, generalized anxiety, and agoraphobia; if these disorders are treated properly then perhaps the SAD will be treated in the fold, as it usually precedes comorbidity (Oltmanns, & Emery, 2010; Seligman, & Wuyek, 2007). In addition, prevention of SAD for young adults leaving for college, and may be away from their home for the first time, may benefit from short excursions away from home prior to leaving for college, perhaps during junior high or high school. It is unknown whether young college students experience SAD because of stress related reasons, or because some students chose to go to school closer to home, but getting used to the idea of living alone or with others in a semi-controlled environment could certainly be helpful (Seligman, & Wuyek, 2007). However, the most successful prevention are for those children who are identified to be shy or have high instances of generalized anxiety as infants or children, who could possibly exhibit signs of SAD in later years, preventative therapies definitely show encouraging signs of improvement (Klein, 2009).
Common treatments for SAD include classic techniques for exposing a fear stimuli and slowly getting the client to get used to the feeling. In the cases of separation anxiety disorder, the fear stimuli would be the feelings of anxiety and fear when being separated from one's attachment figure, and getting use to the idea of being separated (i.e. nothing is going to happen, mother/caregiver will be fine, anxiety will lessen over time, etc.). One example of this therapy is called Counterconditioning, where a child is instructed to sleep alone in their own bed while engaging in relaxation techniques, which are counterintuitive to feelings of anxiety (Doobay, 2008). Another form of therapy is Extinction (or more severely, Flooding), where the child is exposed to the fear stimuli repeatedly until the fear and anxiety is no longer produced because the child will have gotten used to the separation and nothing bad happening (Doobay, 2008). Modeling can also be used, where the child is exposed to various forms of modeling (video, live, or participant), which involves watching another child go through a familiar routine (for example, leaving for school), in a calm manner (Doobay, 2008). These are all forms of classical conditioning, but cognitive therapies can also be employed. A child sees a therapist who helps the child to discover what specific thoughts, beliefs, or behaviors that contribute to the irrational anxiety; the therapist and the child then work together to come up with cognitive restructuring techniques to change the childs thought pattern (Doobay, 2008). Modern day treatments usually include some combination of the above-mentioned therapies, known as Cognitive-Behavioral Therapy, or CBT, which also warrant participation from parents, schools, coaches, etc. (Doobay, 2008). Some forms of therapy utilize CBT in addition to different types of medications that are usually used to treat anxieties in adults, such as SSRIs, placebo, and D-cycloserine (Klein, 2009).
If treatment is not sought, prognosis for children who never get help and grow up with SAD also have a severely high chance of developing agoraphobia and depression as well (Oltmanns, & Emery, 2010). In other words, the outlook for such children and adults is bleak. It is estimated that three to thirteen percent of youth are affected by some form of separation anxiety disorder (equally for males and females) (Doobay, 2007), and in addition the prevalence of SAD for young adults entering college as freshman is 21% are affected (Seligman, & Wuyek, 2007). For those suffering from SAD, their quality of life is severely diminished due to the fact that they cannot leave their attachment figure for any length of time without suffering debilitating panic attacks, among other various symptoms as previously discussed (Seligman, & Wuyek, 2007). The impact on development for children has drastic negative effects on their memory, educational achievement, and high instances of substance abuse (Doobay, 2008), in addition to impairment on their general school functioning, after school activities and developing peer and social relationships (Feigon, Waldman, Levy, & Hay, 2001). As adults who experience SAD as children, there are "higher instances of adjustment disorders, eating disorders, depression," obsessive-compulsive disorder, and attention deficit hyperactivity disorder (Doobay, 2008).
Usually SAD is the main reason for school refusal, which also has the largest impact on parents and family members for school age children (Doobay, 2008). Familial consequences usually include legal problems, school related meetings and issues, child distress, distress on immediate family members, financial distress and lack of supervision for children (Doobay, 2008). Adults with SAD usually experience economic difficulty, medical costs, decreased work productivity and problems developing friendships or social relationships (Klein, 2009).