Separation anxiety is one of the most commonly diagnosed anxiety disorders in childhood. (1) Separation anxiety is a disorder that is classified as a pattern of recurring distress and fear with high intensity triggered by a child being separated from their primary caregivers. When separation does occur, it is often met with the child becoming hysterical, clingy, and emotionally dysregulated. (2) These moments often leave caregivers feeling helpless and children feeling emotionally defeated. Developing autonomy and learning how to tolerate separation from their secure base can be a challenging milestone for many children.
Separation anxiety is typically seen as a developmentally normative experience during infancy and for children under the age of three years old. (1) The presence of significant separation anxiety past these early years may be an indication of the manifestation of a disorder. Separation anxiety disorder is most prevalent among children between the ages of seven to nine years old. (2) The purpose of this blog is to help answer lingering questions that so many caregivers have during parenthood. Why do so many children struggle with separation? How can caregivers best support their little ones? This blog can be utilized as a synthesized guide to provide diagnostic clarity on the disorder, helpful coping strategies, and insight on how to assess severity to understand when it is important to seek professional support for your child.
Symptoms of Separation Anxiety
The following symptoms are commonly exhibited by children with separation anxiety when actual or anticipated separation from caregivers occurs.
Emotional Signs
Recurring and excessive distress, fear, panic, and anxious presentation
Hysteria and intense emotional reactions to parental departures
Ruminating fear-based thoughts related to abandonment, caregivers leaving and never being reunified with them, or something bad happening to them such as “[…] illness, injury, disasters, or death.” (1)
The child develops negative self-beliefs about their safety and wellness being at risk in the absence of their caregiver. Children may perseverate on fears of getting kidnapped, hurt, or lost when their parents are not present. (1)
Behavioral Signs
Significant clinginess that inhibits the child from exploring environments without their caregiver in close proximity. The child is observed to prefer to play closely with caregivers and becomes distressed when the caregiver is out of sight. The child may hide behind or desperately cling to caregivers to plead for them not to leave during transitions.
Frequent tantrums and upset that involve emotional dysregulation
Avoidant behaviors such as refusal to leave home or to transition into daycare, school, or play dates due to fears of being away from caregivers
Regression in behaviors that are inconsistent with the child’s developmental stage (e.g., bed-wetting, thumb-sucking, etc.)
Physical Signs
Somatic complaints such as headaches, stomachaches, nausea, or vomiting
Sleep disturbances may include the inability to sleep alone at night, reluctance to sleep away from home, and recurring nightmares with the theme of separation. (1)
Symptoms must persist for at least a four-week duration and significantly impair the child’s social, emotional, behavioral, and/or academic functioning to be classified as a separation anxiety disorder for children. (1)
Understanding Separation Anxiety
Attachment theory suggests that from birth, humans are preconditioned to seek out and develop bonds with their caregivers. (9) This is first established when caregivers tend to their infant’s physical and emotional needs. Infants depend on their caregiver’s responsiveness to establish a sense of safety and security. As infants transition into childhood, they should begin to seek opportunities for independence more often. It becomes most outwardly apparent that children who develop insecure, anxious, or ambivalent attachment styles often struggle with separating from their caregivers. Although separation anxiety is more commonly correlated with these attachment styles, children who develop a secure attachment style may also experience separation anxiety when undergoing big life changes, such as beginning school. The presentation of separation anxiety can differ depending on the child’s age. Common characteristics based on each developmental stage include:
Infancy: Infants are not born with the innate cognitive ability to understand the process of separation and reunification. When caregivers go away, infants typically become distressed. Infants usually don’t develop an understanding of object permanence until approximately six to nine months. (4) Object permanence is the phenomenon that people and objects can continue to exist even when they are not visibly present. Even after they grasp this concept, infants still often struggle with regulating when separating. Separation anxiety during infancy often presents as spells of crying, flailing legs and arms, and upset. Infants are soothed by the presence of their caregiver’s return, physical contact, and co-regulation. Tiredness, hunger, and sickness can intensify an infant’s separation anxiety because they rely on their caregiver to tend to these needs.
Toddlerhood: Toddlerhood introduces a new dichotomy in which young children continue to feel strongly bonded to their caregiver while also growing curious about exploring more independently. Toddlers with separation anxiety are often observed to prefer to play very closely with their caregivers and continuously need to be reassured that they are still there. If the toddler cannot find their caregiver or perceives they are going to leave, they often engage in emotional meltdowns that can be long and drawn out. Transitions, especially into daycare, are especially difficult for toddlers with separation anxiety.
Preschool-age: Preschool-age children are introduced to many new experiences, such as starting school for the first time and having play dates. This requires socialization with peers and new adults without the comfort of their caregiver beside them. These transitional points in their lives may trigger the onset of separation anxiety. Preschool-age children often display similar behaviors to toddlers, including emotional meltdowns and difficulty with transitions. They also become more verbally expressive in their pleas for their caregiver not to leave.
Older children: Older children may show disinterest in leaving their homes and participating in social activities.
Many Factors Can Contribute to Separation Anxiety in Children Including:
Genetic predisposition if their parents have been diagnosed with anxiety
Neurological factors, including an imbalance of two brain chemicals, norepinephrine and serotonin (5)
Environmental factors such as a history of early attachment disruption, trauma, neglect, death or witnessing an illness of a loved one or pet, parental divorce, moving, or changing schools (6)
Insecure or anxious attachment styles
Coping Strategies for Parents and Caregivers
Gradual exposure and desensitization: Caregivers can slowly build their child’s tolerance for separation by gradually exposing them in small steps. Caregivers can practice this by telling their children that they are going to leave for a very brief period of time and informing them when they will come back. It is often helpful to give the child a task they can complete while their caregiver is gone to help redirect their focus to something other than their worries. A scenario to exemplify this is as follows: a caregiver may tell their child, “Mommy is going to go to the bathroom. You can play dinosaurs while you wait. Watch mommy mean what she says and come right back when she’s done.” The caregiver would then praise their child upon their return. The key to this strategy is repetition. For the child to trust that the caregivers truly will return, they will have to be shown this repeatedly throughout their day. Caregivers can gradually increase the amount of time they’re separated as their child’s comfort increases with practice. Eventually, with repeated exposure, the child will become desensitized to the fear response that separation previously elicited, and they will become more secure in their independence. Play therapists may guide caregivers on how they can practice utilizing a therapeutic technique known as imaginal exposure, which involves using role play to help the child act out scenarios that trigger anxiety prior to actually being exposed to them. The child replicates anxiety-provoking situations by acting them out with toys. Imaginal exposure facilitates habituation and inhibitory learning, which show strong efficacy in decreasing anxiety when practiced repeatedly. (7)
Establishing routines and predictability: Children thrive when they know what to expect. Caregivers can establish daily routines to increase predictability. It is recommended that if your child struggles with separation anxiety, caregivers try their best to create consistent schedules with limited change. Creating visual charts, such as a morning or nighttime routine chart or school schedule, can be a helpful way to teach your child to track their day. These charts can be utilized as a prompt throughout the child’s day to remind them of when they will be reunited with their caregiver as well.
Positive reinforcement and praise: Celebrate your child’s bravery by providing praise when they are able to successfully separate, even if it is only for a brief period of time. This form of positive reinforcement can be extremely encouraging for the child.
Identify ways to cope with missing feelings: It’s important to validate your child’s emotions to help them feel seen and heard. Caregivers can voice empathy with their children about how hard separation is and then help them identify what they can do when they miss someone. Coping strategies that children can practice when they have missing feelings include drawing a picture or writing a note for someone that they miss, keeping a transitional object with them to help them feel safe, asking someone for a hug, looking at a photograph of their family, or holding a stuffed animal to feel less alone. There are many children’s books that provide a narrative for managing separation as well. Anna Dewdney’s Llama Llama Misses Mama, Patrice Karst’s The Invisible String, and Audrey Penn’s The Kissing Hand are all wonderful children’s books that provide this lesson.
Teach emotion regulation skills: Children with separation anxiety benefit from learning strategies to manage their emotions. Examples of emotion regulation skills include learning emotion identification and expression in addition to practicing breathing exercises, meditation, mindfulness, and sensory activities.
Avoid drawn-out transitions: As a caregiver, it can feel impossible at times not to give in to your child’s desperate plea to have you stay when it is time to say goodbye. Most of the time, however, prolonging the separation only worsens it. If caregivers provide inconsistent responses when transitioning, such as sometimes leaving immediately and other times giving in and staying longer, the child is left feeling ambivalent. Parents should try their best to keep transitions routine and brief.
Create a goodbye ritual: Caregivers can reduce their child’s aversion to separation by making it more fun. Hugs, kisses, high fives, and special handshakes can be shared prior to leaving to fill your child up with love for the day. (8) It may also be helpful to provide your child with a transitional object to help them feel connected to you even when you are apart. Examples include family bracelets, worry stones, a small stuffed animal, or a family photograph.
The Importance of Early Intervention
There are tremendous benefits for children who receive early intervention, and it can help shape the trajectory for long-term improved mental wellness. Research shows that early therapeutic intervention can help decrease the severity of ongoing symptoms and reduce the risk of developing an anxiety-related disorder later in life. Therapy that targets separation anxiety often helps children and caregivers undergo a process of identifying patterns and triggers, processing emotions, building skills to work through and manage fear-based responses, and building resiliency.
When to Seek Help from a Mental Health Professional
As a caregiver, making the decision about how to intervene and support your child best can be difficult. If your child’s symptoms of separation anxiety are prolonging beyond the age of three years old and are significantly having a highly distressing impact on the child’s daily functioning, it is recommended that you seek professional help from a mental health provider. The mental health professional can help provide diagnostic clarity regarding the possible manifestation of a diagnosable separation anxiety disorder and how to create a plan of care for how to best treat it uniquely to your child’s presentation. Play therapy and child-centric therapeutic modalities are recommended as the primary forms of therapy to treat childhood separation anxiety. Therapy is most successful when a collaborative approach is utilized, which involves both individual work with the child and a component that involves caregivers. Play therapy is effective in treating children as young as three years old.
Conclusion
Separation anxiety is highly prevalent during childhood. Therapy can not only provide emotional support to the child but can also help alleviate parental stress. Children can leave feeling more in control of their worries. Caregivers can leave feeling more empowered and grounded in their responsiveness.
At Heritage, we have skilled therapists who specialize in working with children and can provide a compassionate approach to supporting them through managing their separation anxiety. We know the power of partnership and working with the family system. We have made a vow to include parents in the process of helping children overcome their challenges. In addition to individual child therapy sessions, parent consultations are scheduled routinely after every four individual child therapy sessions to reflect on progress, introduce parenting interventions, and help generalize psychoeducation and skills learned to treat their child’s diagnosis. To schedule a consultation at Heritage Counseling we invite you to call 214-363-2345.
Sources
https://adaa.org/find-help/by-demographics/children/childhood-anxiety-disorders
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental health disorders (5th ed.).
Bowlby, J. (1978). Attachment theory and its therapeutic implications. Adolescent Psychiatry, 6, 5–33.
