Separation Anxiety Disorder Separation Anxiety

Separation Anxiety Disorder

Separation anxiety is a very natural reaction and very much a part of the normal cognitive development of a child. However, separation anxiety disorder is an abnormal condition where there is excessive anxiety, which is far beyond the normal level for the particular stage of development of the child. Separation anxiety disorder is a precursor for several psychiatric conditions much later in the adult life. Prompt treatment is essential not only for its remission but also for its effectiveness in controlling the development of future psychopathology. A multimodal treatment program involving cognitive behavioral therapy, family based therapy and appropriate pharmacological intervention if necessary, is the best therapeutic approach to effectively manage the disorder.

Introduction

Separation anxiety is one of the most common forms of anxiety and is a part of the normal cognitive development of the child. It usually develops in a child from the 7th month and peaks before 18 months during which period the child does not want to loose the company of the mother or the father even for a brief length of time. Around 4 or 5 years the child is able to understand that the separation is only temporary and therefore effectively overcomes the distress. However, some children may not effectively cope with this change and exhibit symptoms of separation anxiety such as crying, clinging, whining, silence, etc. [Joelle Belmonte] Somatic symptoms such as dizziness, lightheadedness and nausea maybe more common among older children. School refusal is a common behavioral concern among children with SAD. Statistics show that one third of all children diagnosed with SAD have a comorbid depressive disorder. [Bettina E. Bernstein] Environmental stressors such as death of one of the parents or a close person, parental divorce, being raised by over protective or depressed parents are all high risk factors making a child vulnerable for SAD. The DSM-IV defines Separation anxiety disorder as a "common anxiety disorder that consists of excessive anxiety beyond that expected for the child's developmental level related to separation or impending separation from the attachment figure (eg, primary caretaker, close family member) occurring in children younger than 18 years and lasting for at least 4 weeks. [Bettina E. Bernstein] A brief overview of the condition and several studies that discuss the risk factors as well as discussion of the management of SAD would help us better understand the disorder.

Pathophysiology

Separation anxiety is a common condition and is in fact part of the development of the child's natural cognitive development. During the first year of development the infant identifies its caregivers and exhibits attachment and 'proximity seeking behavior'. This is a natural survival mechanism as under the care and protection of the caregiver the child has better chances of development and survival. However, in some children this behavior continues beyond the normal 3 to 4-year period and develops into what is called the separation anxiety disorder. Some studies that tried to understand the biological relevance of the disorder have suggested that endocrine activation during pregnancy as well as early loss of parents affect the cortisol levels which has been implicated in the development of childhood depression, anxiety disorders and other psychiatric conditions. [Bettina E. Bernstein]

Parental loss or separation and SAD

Battaglia et.al (2009) is one of the most recent researches that is both biological as well as sociological in its approach of SAD. The researchers found that SAD was associated with development of panic disorder and both these conditions resulted in an increased sensitivity for inhalation of Co2. The research further demonstrated that early events in the life of the child such as parental loss or divorce had a bearing on all the above-mentioned interrelated facts. The researchers interviewed more than 700 members of the Norwegian institute of public health and data pertaining to panic disorders, separation anxiety symptoms and history of significant early life events such as parental loss were documented. All the subjects were tested for their hypersensitivity to Co2 alongside a placebo test with compressed air. The study found that while genetic precursors were mostly (89%) responsible for the development of childhood separation disorder into panic disorder, significant events in life such as parental loss has a considerable effect on all the three events of study (panic disorder, SAD and sensitivity to Co2). The study concluded that parental loss was an important environmental risk factor and increases the risk for developmental continuity of SAD into panic disorder and Co2 hypersensitivity among such subjects. [Battaglia et.al, (2009)]

Amoros et.al (2008) is a Spanish study that focused on the effects of parental divorce on children developing separation anxiety disorder. A total of 96 Spanish children in the age group of 8 and 12 participated in this study. These subjects were assessed for the existence of symptoms of separation anxiety and general anxiety and were compared with a group of similarly aged children who had an intact family structure. The results from the study showed a marked association between early parental divorce and the manifestation of separation anxiety disorder and a significant difference between the levels of separation anxiety symptoms between the two groups. The study also found that the test subjects had high levels of generalized anxiety. This research attests to the well-known fact that having both parents is vital for the balanced development of children. Frequent contact with the other parent is very important for children growing in single parent households. [Amoros et.al (2008)]

Parental Role In SAD

Researchers from the University of California tested the role of parental intrusiveness as a precursor for SAD. They hypothesized that parents who are very intrusive in every task make the child less independent and more dependent on them. For the study, the researchers chose subjects within the age group of 6 to 13 and having a diagnosis of SAD. In all, 40 subjects participated in the study, which made diagnostic assessment based on interviews. Rating scales were used to measure the level of intrusiveness for which the data gathered was primarily self-reported. The rating scales were so designed to ensure the seven principles of improving the psychometric properties of parental measures were included. Analysis of the gathered data showed a clear association between parental intrusiveness and child separation anxiety as verified by the correlation between the psychometric properties for the intrusiveness measure. The study also showed that parental intrusiveness was strongly associated only for the separation anxiety disorder when compared with other psychiatric conditions. [Jeffery J. Wood, 2006]

Separation anxiety is not just observed among children. In fact, more recently it is observed that adult separation anxiety disorder is a quite common but largely ignored condition. A recent research by Seligman and Wuyek (2007) at the University of Toledo studied SAD among college students. For the study the researchers recruited a group of first semester college students who were separated from their closest caregivers for the very first time in their lives. These subjects were monitored for symptoms of separation anxiety and for their educational performance. The results from the study showed that around 21% of the subjects exhibited separation anxiety symptoms and that students who had such symptoms had a history of SAD or panic attack during their childhood. [Seligman LD, 2007]

Daycare Woes

A recent research report by Unicef concluded that all children should be under the direct care of parents atleast for the first 12 months. The report indicated that despite the wealth of knowledge gathered in the field of childcare and development, government policies are a far cry from providing ideal growing conditions for the child. In particular, the report mentioned the growing concern about daycare centers and the resulting compromise on Childs emotional development. As David Bull the executive director of Unicef UK says, '"The report is also clear that rich nations have often been guilty of making policies based on economic considerations, not the best interests of the child." The report also mentioned the conclusions drawn from several studies in the U.S. And the UK which attest that long hours spent in day care, particularly at a younger age, maybe detrimental for the normal and healthy cognitive development of the child. "high levels of group care before the age of 3 (and particularly before the age of 2) were associated with higher levels of antisocial behaviour at age 3." [The Times]

SAD and development of other Psychiatric Disorders

A recent Japanese study focused on the possible relationship between childhood separation anxiety disorder and the increased risk for development of other psychological conditions. In particular, this research by Akira et.al (2006) studied the relationship between adult anxiety and personality disorders in patients who had a history of childhood separation anxiety disorder. The researchers administered the Separation Anxiety Symptom Inventory (SASI), the 'structured Clinical Interview for DSM-IV Axis II personality disorders' (SCID 2) and the 'Global Assessment Functioning' numeric scale to 136 outpatient subjects with anxiety disorders and 174 healthy subjects. The assessment of the data obtained clearly indicated a positive correlation between SASI scores and patients with a history of anxiety disorders. This correlation was more pronounced among female subjects. The results showed that of the 134 test subjects, 84.3% had no comorbid condition while the rest (15.7%) had atleast one comorbid condition. These subjects also showed a higher SASI score (p = .053). The subgroup with comorbid condition also showed a history of early onset (p < .01) and poor recovery of global functioning (p < .05) when compared to the non-comorbid group. Female subjects also showed higher SASI score (p < .05). This study clearly shows a positive association between childhood separation anxiety disorder and the onset of co morbid psychological conditions in adult life. Particularly, women with childhood separation anxiety disorder were more prone to develop a continuum of disorders in adult life. [Akira et.al, 2006]

A more recent study by Karlovec et.al (2008) followed 10 Austrian students who had a previous history of separation anxiety and school refusal. All the subjects in the study had undergone 12 weeks of cognitive behavioral therapy at the Innsbruck Medical University, Austria, as treatment for separation anxiety disorder. During this follow-up study, the children were aged between 9 to 14 years. The study involved a series of interviews with the parent and the children pertaining to the history of separation anxiety and school refusal. The subjects were evaluated for separation anxiety and other psychiatric disorders using the 'Diagnostic Interview for Mental Disorders in Children and Adolescents' based on the DSM-IV criteria. Analysis of the gathered data revealed that the cognitive behavioral therapy was successful in overcoming school refusal among the students with only one subject continuing to exhibit symptoms of school refusal. However, the results of the study also indicated that all the subjects had atleast 2 psychiatric conditions (based on the DSM -- IV criteria), with some students having 3, 4 or 5 co morbid disorders. Attention deficit hyperactivity disorder (N=6), oppositional defiant disorder (N =4) and agoraphobia (N=3) and obsessive compulsive disorder (N=3) were the other psychiatric co morbid conditions. Overall, 3 subjects were totally recovered while 6 others were in partial remission. This study suggests that children who are school refusers and diagnosed with separation anxiety disorder are at a greater risk for developing other co morbid psychiatric disorders. The study also indicated that children who are successfully treated for separation anxiety might require further monitoring and intervention for other possible psychiatric conditions. [Karlovec et.al, 2008]

Lewinsohn et.al (2008) is another research that studied the predisposition of children diagnosed with SAD at childhood for other psychiatric disorders during adolescence and adulthood. Subjects were chosen from the Oregon Adolescent Depression Project (n = 816). This was a longitudinal study where the subjects were screened for childhood history of SAD, current mental illnesses (at 16 years of age) and followed up into adulthood up to the age of 30. The subjects were assessed twice during adolescence and the diagnostic assessments were repeated again at 24 and 30 years of age respectively. The subjects were divided into four groups SAD (n = 42), other psychiatric disorders (n = 88), 'heterogeneous psychiatric disorders control group' (n = 389) and a control group without any mental disorders (n= 297). Statistical analysis of the data using multiple logistic regression revealed that SAD was a high risk factor (78.6%)for developing other psychiatric conditions. In particular, children with SAD had a high propensity for developing depression and panic attack in their adolescent and adult lives. The results of this study again emphasize the importance of treating SAD promptly not only for its remission but also for its effectiveness in controlling the development of future psychopathology. [Lewinsohn et.al (2008)]