# Motivation and emotion/Book/2017/Separation anxiety in children

* Multimedia presentation (3 min)

## Overview

* Case study
* Lucy is a 6 year old child who lives with her mother and father. Lucy is an only child and is currently enrolled in Kindergarten. Since beginning Kindergarten three months ago, Lucy has refused to go to school and as a result has already missed eight days of school. Fear of being separated from her parents has led Lucy to experience several symptoms of anxiety such as:
* Limited to no sleep, in fear of attending school the next day
* Panic attacks during the middle of the night
* Nightmares
* Refusal to sleep alone
* Hysterical tantrums
* Refusal to engage in anything that requires physical separation from parents
* Withdrawal from school activities
* Withdrawal from socialising with other peers

## Definition of separation anxiety

As exemplified in the case study, separation anxiety is characterised by:
* Recurrent, excessive, distress when separation from home or major attachment figures occurs
* Persistent and excessive worry about losing major attachment figures
* Persistent and excessive fear or reluctance to be alone or without major attachment figures nearby
* Persistent reluctance or refusal to go to sleep without being near a major attachment figure
* Persistent reluctance or refusal to attend school because of fear of separation
* Repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated
(American Psychiatric Association, 2013).

## Separation anxiety in young children

In the early stages of psychoanalytic writings, separation anxiety was described as a basic human disposition which involved concerns about the loss or absence of significant others (Lighezzelo, de Tychey & Thiabeaut, 2006).
Separation anxiety can have a deliberating affect on a child's adaptive functioning and overall well-being.
According to an article published in the Journal of Abnormal Child Psychology (2004), separation anxiety is currently the most prevalent, yet most under-researched anxiety disorder in childhood.
Within modern day society, separation anxiety is identified as an important feature of close interpersonal relationships. Separation anxiety is most commonly examined in the context of mother–child bonds in infancy and early childhood (six-eight months old) (Kins, Soenens & Beyers, 2013; Gifford-smith, Dodge, Dishion & McCord, 2004).The anxiety experienced reflects a child's attempts to grasp familiarity and safety. Many studies have found that, as the child grows older and more confident, the anxiety dissipates (Lighezzelo, de Tychey & Thiabeaut, 2006).
The disorder is closely linked to other psychological disorders and can also be associated with externalizing psychopathology in children (Kins, Soenens & Beyers, 2013). However, separation anxiety in children is differentiated from developmental anxiety by its intensive nature, persistence and the negative impact it can have on a child's development i.e social skill deficits (Kins, Soenens & Beyers, 2013).

## Etiology

* Genetic - According to Cronk et al. (2004), 73% of those who meet diagnostic criteria for separation anxiety have a family history of the disorder. The genetic foundations of separation anxiety have been thoroughly examined throughout a number of large twin studies. [grammar?]Majority of these studies have demonstrated the moderate role of genetic effects in the etiology of anxiety disorders. A further study by Morris-Rosendahl (2002) investigated the nature and extent that genetic predisposition may have on childhood anxiety disorders. Research concluded that the serotonin transporter gene (5-HTT) had a positive correlation with anxiety phenotypes (Morris-Rosendahl, 2002). Furthermore, genome-wide linkage scans for anxiety disorder susceptibility have demonstrated a locus on chromosome arm 7p (Morris-Rosendahl, 2002). Researchers have therefore concluded that any child who obtains the chromosome 7p, is more susceptible to developing separation anxiety (Morris-Rosendahl, 2002).
* Physiological - Evidence has shown that those suffering from separation anxiety are said to have certain chemical imbalances within the brain. Significant or long-lasting stress can change the balance of chemicals in the brain which control mood regulation (Schultz, 2015). A study by Neumann and Landgraf (2012) found that Oxytocin and Vasopressin were the main hormonal regulators of anxiety. Released within the hypothalamic and limbic areas of the brain, an imbalance of these hormones can cause the onset of anxiety at a young age (Neumann & Landgraf, 2012). A second study by Straube in 2016, found that childhood disorders such as separation anxiety and panic disorders were strongly associated with pathophysiological (neuronal) mechanisms and underlying neural alterations.
* Environmental - Often those diagnosed with separation anxiety have been previously exposed to life stress at a young age. This can include the loss of a parental figure (paternal absence), physical or emotional abuse, or separation from an attachment figure (Cronk et al., 2004). Evidence has suggested that another common environmental factor contributing to separation anxiety is parenting behaviour. Studies have proved that parents who display low parental warmth and behaviours that discourage autonomy are often associated with the onset of anxiety disorders in children (Ehrenreich, Santucci & Weiner, 2009). Research has also revealed that intrusive and overprotective parenting behaviours have a strong correlation with the development and maintenance of childhood anxiety disorders (Ehrenreich, Santucci & Weiner, 2009). Furthermore, research surrounding developmental psychology and attachment theories have consistently found that both insecure and anxious attachment types are often at the highest risk of emotional disturbances and psychopathology (Ehrenreich, Santucci & Weiner, 2009).

## Theoretical background

Several psychological theories have been formulated and applied to explain, predict and understand separation anxiety. In most cases, these theories challenge and extend on existing knowledge. These theories devise the main theoretical framework for separation anxiety:

### Bowlby's Attachment Theory (1958)

John Bowlby (1958) is often referred to as one of the founders of attachment theories. He proposed that attachment could be understood through an evolutionary context and stated that the term attachment is adaptive, as it increases the child's chances of survival. Bowlby identified that both infants and mothers have evolved a biological need to stay in contact with each other (Bretherton, 1992). He explained this by demonstrating how a primary caregiver provides safety and security for a child. According to the theory, human infants need a consistent nurturing relationship with one or more caregivers to be able to develop into healthy individuals (Rosmalen & van der Horst, 2016). Any unresponsiveness from a parental guardian may contribute to abnormal behaviour and ultimately, an anxiety disorder. The theorist also stated that certain behaviors such as laughing or crying, can bring about desirable responses such as attention or control. This happens through a process called operant conditioning, whereby the individual learns to repeat certain behaviours to get what they want (Rosmalen & van der Horst, 2016). The theoretical framework has inspired large amounts of research in the area of childhood psychological disorders and is often applied to conditions such as separation anxiety (Rosmalen & van der Horst, 2016).

### Harlow's Monkey Study (1958)

Harlow (1958) was an American psychologist who was best known for his studies of social and cognitive development. Harlow's most famous experiments were those that focused on the maternal-separation and dependency needs of Rhesus monkeys (van de Horst, LeRoy & van der Veer, 2008). In one study, Harlow raised a set of young monkeys in a zoo setting and observed their interaction with each other. The young monkeys were exposed to two unbiological mothers that each had a feeding bottle attached to them. One unbiological mother was wrapped in white cloth while the other was wrapped in a wire mesh (van de Horst, LeRoy & van der Veer, 2008). Results demonstrated that the infant monkeys clung to the unbiological mother that was wrapped in cloth and engaged in extremely violent temper tantrums when removed. Therefore, Harlow concluded that contact comfort is a vital part of mother-child bonding. Harlow then applied his findings to the needs of human children and the onset of separation anxiety in young children (van de Horst, LeRoy & van der Veer, 2008).

### Erikson's Theory (1959)

Erikson's theory (1959) is one of the most influential theories associated with the field of human development. The theory of psycho-social development is centered upon the epigenetic principle, which states that human development evolves through a series of predetermined stages (Dunkel & Sefcek, 2009). Furthermore, the theory states that there is an ideal age associated with each stage and that the resolution of early stages can have a significant influence on the outcomes of later stages (Dunkel & Sefcek, 2009). Based on this epigenetic principle, Erikson stated that there are eight psycho-social stages that become apparent at different times throughout one's lifespan (Dunkel & Sefcek, 2009).
Often stage one of Erikson's theory, Trust vs Mistrust experienced within infancy, is applied to young children suffering from separation anxiety. If primary caretakers ensure they are responsive within the early stages of child rearing, then development of the child tends to move toward a basic sense of trust (Dunkel & Sefcek, 2009). However, if caretakers are not responsive during the early stages of an infant's life, then the infant will develop a sense of mistrust for that person. This can greatly increase the risk of a child developing anxiety (Dunkel & Sefcek, 2009).
Table 1.
Erikson's psycho-social stages of development
| Stage | Psychosocial Crisis | Age |
| 1 | Trust vs Mistrust | Infancy |
| 2 | Autonomy vs Shame | Early Childhood |
| 3 | Initiative vs Guilt | Play Age |
| 4 | Industry vs Inferiority | School Age |
| 5 | Ego Identity vs Role Confusion | Adolescence |
| 6 | Intimacy vs Isolation | Young Adult |
| 7 | Generativity vs Stagnation | Adulthood |
| 8 | Ego interity vs Despair | Maturity |
(Graves & Larkin, 2006)

## Effects of separation anxiety

[Provide more detail]

### Negative consequences

Separation anxiety can cause significant physiological and psychological implications for both a child and parent/caretaker. Listed below are some of the most common implications.
| Negative effects for child: Increased risk of developing mood disorders later in life Limited functional abilities Inability to adapt to change Delayed developmental processes Interference with identity Decreased awareness of internal and external stimuli | Negative effects for attachment figure: Increased anxiety at times of separation Increased risk of insecurities Increased probability of self blame Increased probability of self doubt May lead to chronic vigilance Decreased patience |
(Hong & Sun Park, 2012)

### Positive consequences

Often it is the negative effects of separation anxiety which are focused on within research studies. However, separation anxiety can have some positive outcomes on a child. Often the Post-Traumatic Growth Theory is associated with the positive effects of anxiety. The theory states that positive change can occur, following a traumatic event or stage in one's life. According to further research on the theory, separation anxiety can lead to increased motivation to pursue and reach personal goals later in life (Lee, Wodsworth & Hoptokf, 2006). Separation anxiety can also promote better communication about uncertain feelings and false reassurances, as a person matures (Lee, Wodsworth & Hoptokf, 2006).
Empirical research has demonstrated the survival benefits associated with increased anxiety in early childhood. A study by Lee and colleagues found that anxious children were much less likely engage in risky behaviour later in life (Lee, Wodsworth & Hoptokf, 2006).

## Treatment

Several different treatment strategies are used to treat individuals suffering from separation anxiety. Often medication is used as a last resort. Psychotherapy-based treatment plans are the most commonly used strategies to combat separation anxiety (Bandelow et al., 2014).

### Existential Psychotherapy

Existential Psychotherapy is a treatment commonly used for children suffering from separation anxiety. Existential therapy is often defined as a psychological intervention, based upon the teachings of existential philosophers such as Heidegger and Buber (Vos, Craig & Cooper, 2014). Existential therapies include sessions of psychological interventions that address questions about existence, and which assume that, by overcoming existential distress, psychopathology may be decreased or prevented (Vos, Craig & Cooper, 2014). The therapy integrates techniques such as establishing purpose and meaning, reinforcing interpersonal relationships for the child and parent and enhancing coping strategies (Vos, Craig & Cooper, 2014).
The therapy is based upon the following existential philosophical assumptions[factual?]:
* Humans acquire a universal need for meaning and purpose
* Humans have a capacity for freedom and choice within their lives
* Humans will inevitably face limitations and challenges through their lives
* Humans will function most effectively when these challenges are faced and treated, rather then avoided
Four main components of existential psychotherapy have been designed. Depending on the therapist and the age of the child, different components of existential psychotherapy may be used.
Table 2.
Components of Existential Psychotherapy
| Name of component | Meaning of component |
| Daseinsanalysis | - Encourages therapeutic relationship - Encourages child to express their feelings and develop greater openness |
| Meaning or Logo-Therapies | -Assists clients in establishing meaning and purpose in their lives (didactic techniques) |
| Existential-Humanistic Approach | -Assists clients in facing the ultimate givens of life |
| Experiential-Existential Interventions | -Focuses on helping clients to openly face their experiences and existential processes |
(Vos, Craig & Cooper,2014).

### Cognitive Behavioural Therapy (CBT)

Cognitive–behavioral therapy (CBT) is a highly effective treatment strategy for children suffering from anxiety disorders, in particular separation anxiety[factual?]. This is due to the fact that the treatment plan can be individualized by the therapist to meet the specific needs of the child (van Steensel & Boegels, 2015). CBT therapy sessions focus on the child's thought processes and patterns that lead them to become anxious in the first place. The therapist then puts into place techniques to challenge and alter initial thought and feeling patterns (van Steensel & Boegels, 2015). Below are some of the most common techniques used within CBT, for the treatment of separation anxiety.
Table 3.
CBT techniques and separation anxiety
| CBT Technique | Advantages for separation anxiety |
| Thought challenging | Identifies and challenges negative thoughts about separation and leads to replacement of negative feelings with positive and realistic thoughts |
| Exposure to the fear | Gradually challenges the fear of separation, builds on self confidence and assists in developing skills to combat panic and trauma when separation occurs |
| Cognitive reappraisal | Puts in place processes to help alter the emotional state associated with the fear of separation |
| Focusing attention on personal goals and life satisfaction | Initiates personal goals and realistic outcomes to work towards and takes the focus off the anxiety associated with separation |
| Relapse prevention | Assists in creating plans to stay engaged with therapy. Also creates effective coping strategies and strategies to help deal with separation anxiety when and if it may occur |
(Norton & Price, 2007)

### Family Therapy

A branch of psychotherapy, amily therapy is a treatment strategy which incorporates disorder-specific materials that are appropriate for children of all ages. The therapy is based upon the nature of separation anxiety, within the context of the family (Schneider et al. 2013).The treatment strategy includes components such as parental dysfunction counselling, parenting behaviours and parent-child interactions (Schneider et al., 2013). Several research studies associated with family therapy and separation anxiety have found that parent behaviours and cognitions are highly associated with the onset of children's separation anxiety. Additionally, research has concluded that, unlike other anxiety disorders, separation anxiety requires direct parent training in the treatment stages of the disorder (Schneider et al. 2013).
Family therapy combines an array of counselling techniques such as:
* Communication therapy
* Systemic coaching
* General child-focused therapy
* Parenting techniques
* Psychotherapy
(Schneider et al., 2013).

### Systematic Desensitization

Systematic desensitization is another popular method used among psychology professionals to treat separation anxiety in children (Garber, 2015). The treatment method aims to diminish the fear and/or phobia associated with the child's anxiety - in this case, the separation between the child and caretaker. In order for the treatment to be successful, the client must learn three imperative skills. These skills must be actively practiced over the course of treatment (Garber, 2015):
* Identify and express degree of anxiety to the therapist. In 1969, theorist Joseph Wolpe introduced the Subjective Units of Distress Scale (SUDS). The scale is used as an expression of anxiety, by which a client rates their level of anxiety from one to ten. Another method used to measure anxiety is the fear thermometer, developed by Cohen DeMoor in 1970. Often this method works well with children, as it is basic and easy to report anxiety using analogies (Gruber, 2015).
* Prioritize steps towards fear from least significant to most significant. This results in a hierarchy of fear (Gruber, 2015).
* Develop individualised relaxation techniques, to minimise the power of anxiety. This step is what distinguishes systematic desensitization from flooding (Gruber, 2015)
Research has found that the preferred method of treatment for separation anxiety in children is a carefully structured, gradual onset of systematic desensitization to reduce anxiety (Gruber, 2015).
Test your knowledge - try these quiz questions!
1
Which is not a symptom of separation anxiety?
Hysterical tantrums
Nightmares
Limited to no sleep
Withdrawal from interactions with family members
2
Which is not a negative effect of separation anxiety?
Interference with identity
Increased awareness of internal and external stimuli
Inability to adapt to change
Interference with developmental processes
3
Which answer best describes Cognitive Behavioural Therapy (CBT)?
Focuses on altering thought patterns and processes to reduce anxiety
Develops alternate ways of thinking
Helps client become more aware of negative thoughts
All of the above
4
Systematic desensitization includes the development of relaxation techniques?
True
False :

## Suggestions based on theories and research

* Based on the theoretical framework and treatment options available, some suggestions for future research can be made:
* As suggested in family therapy, it is important to practice 'healthy' separation, schedule separations after naps or feedings and develop a familiar 'goodbye' ritual.
* Engage in family therapy to teach the child and parent the importance of a consistent primary caregiver.
* Participate in regular CBT sessions which confront the issue of separation
* Ensure that the child is being listened to and that the parent completely understands how the child is coping with being afraid
* Participate in regular existential psychotherapy sessions to develop appropriate coping strategies and support networks
* Use the techniques taken from Bowlby's attachment theory, to systematically desensitize the child from fearing separation
* Incorporating these techniques should minimise the onset of separation anxiety symptoms, as experienced by Lucy in the case study.

## Conclusion

Characterised by recurrent, extensive distress, separation anxiety is a prevalent disorder among children. Often separation anxiety can have negative affects on one's adaptive functioning. However, through the findings of theoretical research studies, several effective treatment options have been put in place to assist in decreasing the effects of separation anxiety. These include Cognitive Behavioural Treatment, Existential Psychotherapy, Family Therapy and Systematic Desensitization. As suggested in therapy, it is important to practice 'healthy' separation from children and to develop effective coping strategies and support networks to help treat separation anxiety.