Separation Anxiety Disorder
Separation anxiety is defined as feelings of negative emotions such as loss, loneliness, and sadness that are experienced by individuals when they are separated from an important person in their life. Separation anxiety is typically used to describe the reaction of an infant who is separated from a major caregiver such as the mother or father. Separation anxiety, however, has also been noted to occur at other times during an individual's life. For example, the term is used to describe parents' reactions to leaving their young infant (Hock, McBride, and Gnezda 1989). Separation anxiety may also be experienced, at any age, when a significant person in one's life is lost due to death.
Theoretically, separation anxiety in a young infant is considered to be a normal process of development which helps ensure the infant's survival (Bowlby 1969). According to the ethological theory, an infant experiencing a separation from a caregiver will produce behaviors such as crying, following, and calling, which have the goal of ending the separation from the caregiver and allowing the infant to stay in close proximity to the caregiver. By staying close to the caregiver the infant increases the likelihood that he or she will be nurtured and protected and therefore will survive.
The infant's cognitive development is important in the development of the infant's separation anxiety. The development of the infant's memory and the ability to recognize when someone is familiar—or unfamiliar—is a key component in the development of the infant's separation anxiety and protest. Infants show a strong preference for people with whom they are familiar. Once the infant can recognize a familiar caregiver the infant will protest the separation from that caregiver and show a wariness of people who are strangers.
Separation anxiety develops over the infant's first year of life. Initially, a young infant does not differentiate between those persons who are familiar and those who are unfamiliar and therefore shows no sign of anxiety during separations from their major caregivers. At this early age infants readily accept the interaction of strangers and do not protest separation from caregivers. At approximately seven months of age the infant begins to recognize caregivers and it is at this time that the infant will begin to express separation anxiety and direct proximity seeking behavior (e.g., cries, smiles, and coos) toward familiar caregivers (Shaffer and Emerson 1964).
When the infant becomes mobile he or she becomes more active in contact-seeking and separation protest behavior. With the development of creeping and crawling the young infant, instead of just calling and crying, will follow a major caregiver when he or she leaves the room. Ethological theory assumes that the development of separation anxiety serves a functional purpose of causing the now mobile child to stay in contact with the caregiver.
The overt manifestations of separation anxiety (e.g., crying, calling, and following) typically peak between twelve and eighteen months of age. As the toddler matures, usually after the child's second birthday, he or she begins to develop cognitive and behavioral means to cope with separations and separation anxiety decreases. Examples of methods used by older children to cope with these separations are maintaining a mental picture of their caregiver and keeping themselves busy during separations. Older children also are beginning to understand that separations are temporary and that their caregiver will return shortly.
The development of the infant's caregiverdirected separation protest and contact-seeking behavior coincides with the development of the infant's attachment to his or her major caregivers. It is over the course of the infant's first year that the quality of the infant's attachments to major caregivers develops. The quality of the infant's attachment to major caregivers does not influence the development of separation anxiety, but it may influence the infant's overt separation protest behaviors and the child's ability to cope during separations. Insecurely attached infants may have heightened or decreased levels of separation protest and their separation anxiety may not be reduced when their caregiver is present. Though infants who are securely attached to their caregivers also protest separation, their separation anxiety decreases with the presence of their caregiver (Ainsworth et al. 1978).
The infant's security of attachment originates within the interactions of the infant-caregiver dyad during the infant's first year of life. For example, when the caregiver is sensitive to the infant and responds appropriately to the infant, the infant will develop a secure attachment. A securely attached infant is confident that their caregiver will be available when they need the caregiver and separation anxiety is decreased. However, if the infant has experienced rejection from a caregiver or is unsure of the caregiver's responsiveness the infant may develop an insecure attachment. The insecurely attached infant's separation anxiety will be enhanced due to the infant's lack of confidence in the caregiver's availability.
The degree to which the infant experiences separation anxiety is influenced by many factors besides quality of attachment. For example, the caregiver's behavior immediately proceeding the separation will influence how long the infant protests the separation (Field et al. 1984). Preparing a child for the separation by letting the child know that the separation is going to occur and that the caregiver will return, instructing the child on what to do during the separation (e.g., play with the toys), and making the leave-taking short has been found to decrease overt signs of separation anxiety.
Infants also display greater separation anxiety when they have less experience with separation from their caregiver ( Jacobson and Wille 1984). When an infant has multiple caregivers (e.g., mother, father, grandparents, and baby-sitters) less separation protest is observed. It is assumed that children with multiple caregivers are familiar with what occurs during separations, understand that these separations are temporary, and have learned how to cope with these separations. These children may also have developed attachments to multiple caregivers and/or may have learned to gain comfort from other adults.
The level of separation anxiety expressed by infants is also influenced by cultural practices. Typically, Japanese infants have little or no experience with maternal separation. Japanese mothers also give their infants their total attention and positive regard. Japanese infants have an immediate and negative response to separation from their mothers. These infants appear to have a high level of separation anxiety (Van Ijzendoorn and Sagi 1999).
Though separation anxiety is considered to be part of normal development, when a young child's separation anxiety is severe and prolonged he or she may by diagnosed with Separation Anxiety Disorder (American Psychiatric Association 1994). Separation Anxiety Disorder is diagnosed when a child, under the age of eighteen years, shows excessive anxiety about separation from a primary attachment figure or home which lasts for at least four weeks. Some of the symptoms associated with this disorder are unrealistic worry that either the child or the caregiver will be harmed during separation, refusal to go to school, and becoming physically ill or complaining of illness before or during the separation. This disorder is estimated to occur in approximately 4 percent of children (Anderson et al. 1987). It is assumed that Separation Anxiety Disorder may manifest itself in other psychological disorders when the child becomes an adult; however, little research has been completed to support this hypothesis (Majcher and Pollack 1996).
The symptoms associated with Separation Anxiety Disorder may decrease the number of positive interactions that the child has with his or her parents. For example, a child's school refusal may lead to daily prolonged negative interactions, with the parent attempting to get the child up and ready for school and the child refusing to cooperate and complaining of physical illness as a means to avoid school. Parents may respond to school refusal with increased harshness and develop feelings of guilt because of their child's behavior and their inability to manage this behavior.
The possible causes of Separation Anxiety Disorder are diverse and it is often difficult for the therapist to determine the exact cause. Cases of Separation Anxiety Disorder have been noted due to prolonged parental separation (e.g., if parent or child is hospitalized) and death of a significant figure in the child's life (e.g., grandparent). In some cases, the parents have also been found to have experienced a high level of anxiety as a child. Though theory and research show a connection between separation anxiety and protest and the child's quality of attachment, research is still needed to determine if the quality of the child's attachment relationships has an impact on the development of Separation Anxiety Disorder (Greenberg 1999).
There are several treatment options available for children with Separation Anxiety Disorder. Research is still needed to determine the most effective method to treat this childhood disorder. Therapies used to treat Separation Anxiety Disorder include behavioral therapy and cognitive-behavioral therapy, which have been found to be effective in decreasing the level of anxiety and overt separation protest behaviors produced by children (Mash and Barkley 1998). Examples of behavioral and cognitive-behavioral therapy include rewards for appropriate behaviors, modeling of appropriate behavior, and systematic desensitization.
With systematic desensitization the child is exposed to a series of events with each event in this series eliciting more separation anxiety than the preceding event. The first event usually causes the child to experience very little separation anxiety, the next event would cause the child to experience a little more separation anxiety, and so forth. These events may be imagined by child, if they are old enough and have the cognitive ability to imagine events, or the environment is manipulated so that the child actually experiences the events. Starting with the least anxiety producing event (e.g., the child imagines his/her mother explaining that she will need to go to the store to get an item of food for dinner or the mother actually explains to the child that she will need to go to the store to get an item of food for dinner), the child is taken through relaxation steps or counter conditioning (child receives a positive reward) that leads to a decrease in the anxiety. Once the child is experiencing little or no anxiety to this stimulus the next separation anxiety producing event is presented.
Family therapy and pharmacological interventions have also been used to treat Separation Anxiety Disorder. Family therapy may include child management training and parent education. The parents are given information about the disorder, how to manage their child's reactions to separations and school refusal, and how to support their child's emotional needs. In most cases family therapy is provided together with individual therapy for the child. Pharmacological interventions for Separation Anxiety Disorder are relatively recent and are usually integrated with the other forms of therapy described above. More research is needed to determine the effectiveness of pharmacological interventions on Separation Anxiety Disorder (Allen, Leonard, and Swedo 1995).
Treatment for school refusal, one of the possible symptoms of separation anxiety, varies depending upon how quickly the child develops this symptom. For children who develop this symptom quickly, a method developed by Wallace Kennedy (1965) appears to be effective. Kennedy's approach is to get the child into school, keep them at school, and provide them with positive reinforcement for attending school as well as modeling appropriate behavior. For other children, the development of school refusal occurs over an extended period of time and many different factors may play a role in the development of this symptom. In these cases treatment usually consists of individual therapy for the child as well as family therapy.
See also: ANXIETY DISORDERS; ATTACHMENT: PARENT-CHILD RELATIONSHIPS; DEVELOPMENT: COGNITIVE; DEVELOPMENTAL PSYCHOPATHOLOGY; LONELINESS; SCHOOL PHOBIA AND SCHOOL REFUSAL; SEPARATION-INDIVIDUATION; SHYNESS: THERAPY: FAMILY RELATIONSHIPS; THERAPY: PARENT-CHILD RELATIONSHIPS
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DIANE E. WILLE
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