Tina is in year 1, lives with her Mum and her older brother, and is very anxious about going to school. This issue has been a challenge for Tina and her Mum for some time – from kindergarten onwards.
However since starting year 1, Tina has become even more anxious. Every school morning, while Mum tries to convince her that she will be okay at school, she cries, yells, says she is sick, throws things, says “I hate you so much” and hits her Mum. Sometimes she vomits. Tina gets a stomach ache and headache most afternoons when she thinks about school the next day.
Tina is now only going to school once a week and has missed over 50 days of school this year.
As well as being anxious about going to school, Tina also feels uncomfortable staying with her grandparents when Mum goes out on the weekend, and does not want her Mum to leave when she goes to other children’s houses to play.
As I’m sure you have guessed, Tina (not a real person) is a child with separation anxiety, the most common anxiety disorder diagnosed in childhood – and school anxiety.
Definitions and Prevalence
Separation anxiety is defined as “developmentally inappropriate and persistent distress about being apart from home or love ones”
There are three important words in this definition: “developmentally” “inappropriate” and “persistent”. All of these are needed for a child to be given this diagnosis.
In contrast, it is “developmentally appropriate” for babies, toddlers and younger children to be upset about being asked to spend any time apart from parents/caregivers, and also for older children to feel this way at least some of the time.
However some children get more distressed more often than what is typical for a child’s age and culture, it happens very often or all the time, and it causes a great deal of stress for them and their family. In these cases separation anxiety is often diagnosed.
Approximately 4-5% of children will ‘meet the criteria’ for a separation anxiety disorder.
One child’s separation anxiety may be different from another child’s separation anxiety
Like all mental health concerns, separation anxiety exists on a spectrum. Mild and subdiagnostic threshold separation anxiety is extremely common and usually resolves without much intervention and often when teachers/counsellors/others provide psycho-education for the parents this is all that is needed. It is quite satisfying to work with these families and see quick and “easy” results.
However, we have also worked with children (and sometimes teens) who have extremely distressing experiences and reactions when faced with the concept of separation. Like the story of Tina above they will often vomit, have severe stomach pain or headaches, scream/yell, have a panic attack, sob, hit, kick or punch others. They are terrified, distressed and desperate.
I make this point because if we should know that working with child/family with mild separation anxiety is quite different to working with and supporting a child/family with severe separation anxiety. Supporting these children is often a complex and really tough job without any easy or quick solutions.
Causal Factors for Separation Anxiety
Like all emotional health challenges, there is no one factor we can say which causes separation anxiety. However here are the three main categories of factors which are often involved in anxiety generally, and probably separation anxiety specifically.
Genetic research shows that anxiety is at least partly inherited from parents (probably up to 30% of anxiety can be attributed to genetic factors).
Differences in infant temperament show that some babies are much more likely to have stronger negative and anxious responses (“reactive”) to their environment than other babies – even from the first weeks of life. These infants grow up to be more anxious than their ’”non-reactive” infant peers.
Other research shows clear physiological differences between children with higher and lower anxiety. For example, some research shows more anxious children have abnormal neurotransmitter systems, have “overactivity” in the limbic system, others show chronically raised cortisol (a hormone in the brain/body) levels, others show larger increases heart-rates after loud noises.
All of these studies support the theory that there are some purely biological factors which cause anxiety in children.
“Intra-personal” psychological factors
As well as biological factors, we know that children who are more anxious than others also think and act differently. For example, more anxious children are more likely to be those who find it difficult to cope with uncertainty, who notice danger quickly and interpret situations more negatively in general.
Children who experience health challenges, family poverty or stress, difficulties with peers or learning problems are all more likely to experience separation anxiety than children who do not have these challenges in their environment.
Although a sensitive topic, I would be remiss to not mention that another environmental factor is how parents interact with children. Research has suggested that if parents “over control” children, protect them from and do not encourage them to have age appropriate independent activity, or interact with them in harsh or neglectful ways then children are more likely to experience anxiety.
These parent behaviours are only one of the factors linked to anxiety of course, and they may be more or less important in any specific situation. To be clear: there are many children who have parents/caregivers who act in calm, independent-promoting, loving ways who are still highly anxious.
Interaction of Factors
It is likely that causal factors interact with each other – for instance, children who are biologically more anxious are more likely to have parents who are more concerned about them (a child with high levels of anxiety is an extremely stressful experience for a parent) which may then inadvertently make the child more anxious – and so on.
Progression and Course
Most children do experience lower levels of separation anxiety as they get older. One study found that even over the course of 18 months, 80% of 5 to 7 year old children with separation anxiety improve and 60% are entirely better (without symptoms) – and this is without any formal intervention or treatment.
On the flip side however, this means 40% of children with separation anxiety will still struggle 18 months later. Furthermore, even if children with separation anxiety do get less anxious about separation as time goes on, they may also experience other longer term mental health problems. One study found ¾ of children with separation anxiety developed another mental health disorder in young adulthood.
Some authors also theorise that treating and intervening early may prevent problematic patterns of neurological development. Their argument is that excess anxiety in children may be linked to accelerated development of pathways and structures associated with fear in the long term – and therefore, in contrast, intervention might stop this from occurring.
Treatment for Separation Anxiety
Evidence based or manualized treatment for separation anxiety generally has the same few key components. I’ve summarized these below (and added some aspects which I have also found to be helpful in working with this group)
Psycho-education (What is anxiety?) and increasing motivation (Great things about Big Kid Time)
It is important for children to understand what anxiety is and what is happening to them when they feel anxious. We need to explain this to them in simple language (see below for sentence ideas which might be helpful). Sometimes this requires several conversations with children, and to use visual information (like drawings and posters) while we are talking.
I know you don’t like it when Mum/Dad are not there. This is called feeling anxious or worried. When this happens your heart beats fast, you have worried thoughts and you want to hold on to us. Sometimes you feel angry, and feel sick. This is what happens when people feel anxious or worried. Feeling anxious doesn’t hurt your body but it doesn’t feel very good.
It is also vital that children know it is important for them to practice and work on being less anxious slowly over time and that not working on this can make things worse for them over time. For example, in the clinic we draw a “loop” diagram with arrows to show that when we feel anxious we then (understandably) avoid scary situations, but that avoiding these situations makes us feel MORE anxious as time goes on. We also come up with lists of positive reasons for children to practice acting bravely so they have more motivation to do this work. We might use sentences like:
It is not your fault when you feel anxious and it happens to lots of people. But it is important to work on coping better with your worry. We need to help you feel and acting bravely without us there as you get older. It is good for kids to have “big kid time” when they are away from their mums and dads and caregivers and with other safe people.
We need to support parents/caregivers to give these same messages to children. I talk with parents about the importance of their non verbal messages as well as their words. It is helpful to ask parents to make sure their tone of voice, expressions on their face and body language tells their children both that they care about them AND that as parents they are in charge and not worried about them. If children sense either that parents don’t care very much about their anxiety OR that they are really, really worried about their children’s anxiety – then this can make children’s anxiety higher.
Cognitive restructuring: Helping children identify calm thoughts
One of the ways to help children feel less anxious is to help them identify and practice saying “calm thoughts” before they have to be apart from parents, which they can then use. This might involve us writing sentences, or drawing pictures (or using clay or other materials) to represent these sentences. For example, we might say things like:
Calm thoughts are things we can say or remember when we feel worried. We can write/draw some calm thoughts which you can use when you are anxious about us not being there. For example, let’s think of some calm thoughts like:
I will be okay without mum/dad because…………
Mum/Dad will be okay without me because………….
There are good things about me being apart from Mum/Dad which are……………
I can cope when I am ………………. Because………………..
If I feel anxious I can do ……………..which will help me
Physiological arousal reduction/relaxation: Helping children learn to relax their bodies
Most research suggests that reducing physiological tension results in lower anxiety levels.
This means it can be beneficial for children to “practice” relaxation strategies for them to use when they are anxious. This means teaching children to “make their muscles floppy” and “do slow breathing”. It then means regularly practicing these strategies and then when they are skilled at doing them in neutral situations, reminding them to use them when they are anxious.
For example, we might say things like:
If we can make our bodies relaxed, this often makes us less worried. We can make our bodies relaxed by making our muscles floppy, and breathing a little bit slower. We can practice floppy muscles and slow breathing every night before bed for a while. When you are really good at relaxing our bodies, you can do this when you are going to be away from me/us.
In my experience, children with mild separation anxiety respond well to relaxation strategies. However children with severe separation anxiety are less likely to be able to independently relax their bodies – so for these children I will often switch to the next strategy, which also lowers physiological arousal but indirectly.
Re-direction of Attention: Helping children to use distraction and “busy brain” plans
An important strategy for children to manage separation anxiety is to help them redirect their attention on to other topics.
Thinking about or focusing on other activities or topics “activates” other systems and regions of the brain other than those involved in anxiety and threat and helps children feel calmer. We need to help children develop a plan for what they will do to focus their attention on interesting activities and topics while they are separated from mum and dad. I call this a “busy brain” plan and make sure this is in writing and practiced repeatedly with families before children practice being away from them. For many children, the most active type of distraction is social interactions.
For example, some sentences involved in this might be:
When we think about and do interesting things, this helps us feel calmer. We can make a “busy brain plan” with some activities or topics you can do when you are away from us/me. Let’s write/draw some ideas, what will be the first thing you do to keep your brain busy after you say goodbye at school in the morning? Who will you talk to/do something with first?
Exposure: Helping children act in brave ways
Exposure has been consistently found to be one of the most important parts of any intervention for anxiety disorders. This means that we almost always need to help families engage in and commit to exposure practice where they are apart from their parents for short and regular periods of time.
Exposure generally works best however when it is very regular – ideally daily or even multiple times per day. Regular practice is better than long periods of practice. In addition, children need to practice acting bravely (ie saying a positive goodbye, keeping their brain busy, using their calm sentences and relaxing their body) rather than just “enduring” and waiting for the clock to run down.
Here are some sentences we might use to explain exposure to children.
We will do little practices of you having time apart from Mum/Dad to teach your brain that you are safe and help you act bravely. You can use all your ideas we have talked about to help you feel calm. I know you might feel anxious but remember when we ACT brave, even when we are feeling anxious, our brain starts to learn that everything is okay. We will need to do LOTS of practices, but they can be short. We can tick off every practice you do on this paper so you can see how you are going.
If we do all this, will it help?
Most children with separation anxiety who get the kind of treatment described above feel less anxious.
One study found 90% of 5-7 year old children significantly improved and 76% of them no longer met criteria after receiving treatment and support for anxiety. Another study found (over 20 sessions) found 60% of children improved so much that they didn’t meet the criteria for a diagnosis of separation anxiety (compared to 20% of children who didn’t get any treatment).
As you can see from this data however, there is a proportion of children with separation anxiety who either don’t improve or improve very slowly. There is some evidence that SSRI’s can be helpful for this age group, but also some concerns about the long term effects/side effects profile for using this medication with children.
As with many topics related to child psychotherapy, there are gaps in the literature (there have been very few studies on this topic in the last 10 years) and it appears we still have a way to go to improve our understanding of effective treatment – especially for non-responders.