Separation Anxiety Disorder: Causes, Risks, and Treatment

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 seventh month and peaks before 18 months, during which period the child does not want to lose the company of the mother or father even for a brief length of time. Around age four or five, the child is able to understand that 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, and silence (Joelle Belmonte). Somatic symptoms such as dizziness, lightheadedness, and nausea may be more common among older children. School refusal is a common behavioral concern among children with separation anxiety disorder (SAD). Statistics show that one third of all children diagnosed with SAD have a comorbid depressive disorder (Bettina E. Bernstein).

Environmental stressors such as the death of a parent or close person, parental divorce, and being raised by overprotective or depressed parents are all high-risk factors making a child vulnerable to 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 (e.g., 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 discussing risk factors, as well as the management of SAD, helps to better illuminate the disorder.

Pathophysiology

Separation anxiety is a common condition and is in fact part 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: 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 three-to-four-year period and develops into separation anxiety disorder.

Some studies that have tried to understand the biological relevance of the disorder have suggested that endocrine activation during pregnancy, as well as early loss of parents, affects cortisol levels, which have been implicated in the development of childhood depression, anxiety disorders, and other psychiatric conditions (Bettina E. Bernstein).

Parental Loss, Divorce, and SAD Risk

Battaglia et al. (2009) represents one of the most recent studies that is both biological and sociological in its approach to SAD. The researchers found that SAD was associated with the development of panic disorder, and that both conditions resulted in an increased sensitivity to CO₂ inhalation. The research further demonstrated that early life events such as parental loss or divorce had a bearing on all of these interrelated findings. 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 subjects were tested for hypersensitivity to CO₂ alongside a placebo test with compressed air. The study found that while genetic precursors were mostly responsible (89%) for the development of childhood separation disorder into panic disorder, significant life events such as parental loss had a considerable effect on all three outcomes studied — panic disorder, SAD, and sensitivity to CO₂. The study concluded that parental loss was an important environmental risk factor that increases the risk for developmental continuity of SAD into panic disorder and CO₂ hypersensitivity (Battaglia et al., 2009).

Amorós 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 between the ages of 8 and 12 participated in this study. These subjects were assessed for 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 showed a marked association between early parental divorce and the manifestation of separation anxiety disorder, as well as a significant difference between the levels of separation anxiety symptoms between the two groups. The study also found that the subjects had high levels of generalized anxiety. This research attests to the well-established importance of parental presence for the balanced development of children, and underscores that frequent contact with the non-custodial parent is very important for children in single-parent households (Amorós et al., 2008).

Conclusion

Separation anxiety is a very natural reaction and very much a part of the normal cognitive development of a child — an intrinsic component of the bonding process between the child and the parents. However, separation anxiety disorder is an abnormal condition in which excessive anxiety far exceeds what is expected for the child's particular stage of development. Overprotective parenting, parental depression, and other environmental stressors such as early loss of parents or close persons are all high-risk factors that may render a child vulnerable to SAD.

As the studies reviewed above demonstrate, separation anxiety disorder is a significant precursor to several psychiatric conditions later in adult life. It is therefore important to treat SAD promptly, 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 when necessary represents the best therapeutic approach to effectively managing separation anxiety disorder.

References

Osone, A., & Takahashi, S. (2006). Possible link between childhood separation anxiety and adulthood personality disorder in patients with anxiety disorders in Japan. The Journal of Clinical Psychiatry, 67(9), 1451–1457.

Karlovec, K., & Yazdi, K., et al. (2008). Separation anxiety disorder and school refusal in childhood: Potential risk factor for developing distinct psychiatric disorders? Journal of Clinical Psychiatry, 10(1), 72–73.

Lewinsohn, P. M., & Holm-Denoma, J. M., et al. (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.

Wood, J. J. (2006). Parental intrusiveness and children's separation anxiety in a clinical sample. Journal of Child Psychiatry and Human Development, 37(1).

Seligman, L. D., & Wuyek, L. A. (2007). Correlates of separation anxiety symptoms among first-semester college students: An exploratory study. Journal of Psychology, 141(2), 135–145.

Battaglia, M., & Pesenti-Gritti, P., et al. (2009). A genetically informed study of the association between childhood separation anxiety, sensitivity to CO2, panic disorder, and the effect of childhood parental loss. Archives of General Psychiatry, 66(1), 64–71.

Amorós, M. O., Sánchez, J. P. E., & Carrillo, X. M. (2008). Separation anxiety disorder in a sample of children of divorce. Psicothema, 20(3), 383–388.

Bernstein, B. E. Anxiety disorder: Separation anxiety and school refusal. Retrieved April 14, 2009, from

Belmonte, J. Separation anxiety and separation anxiety disorder. Retrieved April 14, 2009, from http://www.helpguide.org/mental/separation_anxiety_causes_prevention_treatment.htm