Separation Anxiety

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Separation Anxiety

By David F. McMahon, M.D., FAPA

(August 24, 2006) -- It is a familiar picture: the preschoolers or kindergarteners are lined up to go to camp or school. At least one child in the group starts crying loudly, not wanting his or her parent to leave. He may grab the parent's leg, or she may throw herself on the ground and have a tantrum. Usually the parent is mortified at their child's behavior and tries to coax the child into going along. The other parents may look annoyed or look away, perhaps thinking, "poor baby" or "big baby."

The emotional problem behind these behaviors is classified as a separation anxiety disorder. These diagnoses in turn belong to the larger class of illnesses known as the anxiety disorders.

Before continuing I want to make an important point: the diagnosis of this disorder is dependent on the age of the child. Behavior that suggests a separation anxiety disorder in a five year-old child would probably be considered normal in infants and toddlers.

Taken as a group, anxiety disorders are so common that the U.S. Surgeon General's report states, "The combined prevalence*is higher than*all other mental disorders of childhood and adolescence." For instance, in the 9-17 year-old age group, about 13 percent have anxiety disorders, with roughly 4 million children and adolescents having significant dysfunction.

Because the diagnosis is age-dependent, the American Psychiatric Association has developed an elaborate set of criteria for this illness. The core definition is, developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached (DSM IV). This is evidenced by the child or adolescent having at least three symptoms from a list of eight. For example, the child might show "recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated." Space does not allow listing the other seven, but they address issues of repeated nightmares, school avoidance and physical symptoms like the familiar complaints of nausea and "stomachache" seen in children.

The four other criteria specify that the problem begins before age 18 and must go on for at least a month. Also, it has to create "clinically significant distress or impairment" and the disorder cannot be part of another serious mental illness. The disorder may appear suddenly in a child or may evolve from a stressor like a new school or death of a pet or a relative. Even though onset in adolescence is not frequent, the disorder can persist and cause problems in leaving for college. In addition to appearing after a stressor, this illness is more common in families that are "close-knit" and may also be more likely in children that have been traumatized, especially physically or sexually. In the background may be "an overprotective parent who gives the message to a child that the world is a dangerous place," according to the American Academy of Child and Adolescent Psychiatry. More subtle psychological conflicts between parent and child may be at work, which is why psychiatric evaluation may helpful.

It is easy to see how a child suffering from this disorder may miss out on a number of good childhood experiences, like staying at a friend's house, going to camp or on a school trip, or even going to school itself. On the other hand, for a child living in a dangerous neighborhood, a fear of going outside may reflect reality rather than being a symptom. Thus, the context of the child is an important aspect of making the diagnosis.

Not wanting to go to school is most common in children in the 5-7 and 11-14 age groups, when children are challenged by the transitions into grammar and middle schools respectively. Parents need to pay particular attention to a child often being sick from tenseness or anxiety, feigning illness or wanting to stay home with what amount to minor complaints. These complaints may disappear once the child is told he or she can stay home.

The long-term consequences of this disorder can be serious. A child suffering from the school phobia type of separation anxiety may have academic trouble or difficulty making friends. Untreated, these children may go on to develop other anxiety disorders like panic disorder and agoraphobia as adults.

Treatment of this condition depends on the severity of the condition. Simple separation anxiety may not need treatment beyond the parent's warm and loving support coupled with encouraging the child to go to school. AACAP points out that, "If a child is slow to warm up, introducing new situations slowly and with reassurance can decrease the anxiety level."

Mild cases of school phobia may be treated by a pediatrician, and usually require that a rule be established that the child must go to school. If a child exhibits a continuing difficulty with separation anxiety psychotherapy is the treatment of choice. In psychotherapy, each child's specific mix of genes, family experience and life outside the home can be explored and hopefully resolved.

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Exploring the process by which children grow from infants to adults who are able to more or less cope with our world, reminds us once again "children are not just little adults."

Dr.David McMahon, FAPA Head of Geriatric Psychiatry Services, Health and Education Services Medical Director for Geriatric Psychiatry, Center for Healthy Aging is on the medical staff at Beverly Hospital and Addison Gilbert Hospital, Gloucester..

Last updated -08/06

Separation Anxiety

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