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Key points
- Separation anxiety disorder (SAD) is a persistent and developmentally inappropriate pattern of fear during separation.
- A child’s high-intensity reaction can prompt the parent to develop an overly protective response style.
- Parents can nurture, encourage and support their children while also setting clear expectations for participation.
Meghan has always been an inhibited child. Despite having a stable and warm home environment, the 5-year-old looks upon the world with wary, tentative eyes. Of most significant concern to her parents, Meghan can have severe tantrums when needing to separate from her caregivers. Meghan staunchly refuses and grabs her mom’s hand when being dropped off at preschool. Her parents give her lots of hugs and extended goodbyes. This interaction often ends with Meghan's teacher carrying her into the classroom, screaming and crying. This causes great distress to Mom and Dad, as well as to Meghan.
Anxiety about separation naturally peaks at around 18 months of age. Another peak can occur when the child starts schooling or daycare arrangements. While many children have strong attachments to their caregivers, it is important to distinguish developmentally appropriate anxiety from extreme and excessive behavior patterns.
Separation anxiety disorder (SAD) is a persistent and developmentally inappropriate pattern of fear during separation. The distress can manifest in a variety of ways. When faced with an impending separation, children with SAD may cling to the caregiver, bargain, refuse, make demands, or have a meltdown to avoid the feared situation. To reduce the immediate anxiety, parents may excessively reassure the child, stay with the child and refuse to leave, do a task for the child, or display anxious behaviors that inadvertently reinforce the child’s anxiety.
The Anxiety Cycle
Without treatment, separation anxiety can become more ingrained and resistant over time through a cycle of negative reinforcement. The child's negative behaviors are reinforced when they lead to a desired outcome (i.e., avoidance or removal of the feared situation by the adult). And it is a reciprocal relationship. A child’s high-intensity reaction can prompt the parent to develop an overly protective response style.
Let’s say 7-year-old Becky is afraid of attending a new camp program. She feels nauseous and shaky and tries to convince her parents that she cannot attend. “I can’t go,” “I don’t know anyone,” “I will be too scared,” “I don’t feel good,” “I will be sad all day.”
This upset reaction may escalate due to Becky’s distress and desire to avoid the situation. Her parents may experience considerable distress and doubt her ability to cope. They also may doubt their capabilities to withstand the meltdown. Becky may sense and absorb her parents’ anxiety, magnifying her response and belief that the situation is unsafe.
If her parents decide that the camp program is not a good fit or let her stay home because of her reaction, the reaction becomes reinforced. That is, she learns that the reaction is an effective means of avoiding the feared situation. In this way, reactions can become stronger and more ingrained over time.
What Parents Can Do
Parents accommodate as an act of love and an attempt to appease the anxiety. Unfortunately, what results is kids that don’t feel confident in their capabilities to face anxiety and be independent. They don’t develop the coping skills they need to navigate the world. While short-term anxiety may increase as a child faces a fear, long-term anxiety is reduced, and coping skills and confidence increase.
Parents can and should nurture, encourage and support their children, while also setting clear expectations for participation.
Here are six key steps for managing separation fears in your child:
Talk with your child about the upcoming separation using a positive, calm, and matter-of-fact demeanor. Convey key facts and prep them on the plan, but be brief. For example, “Tomorrow we are starting your gymnastics class. There are so many fun things to do there, and I think you will enjoy it. Mommy will be there to walk you in, but then I will sit in the observation area with the other parents.”
If your child expresses fear, validate and acknowledge the fear without getting drawn into endless negotiation or emotional debate. “I can understand why you are feeling anxious. It can feel scary to do new things. But I also know how strong you are and how much fun you will have. If you feel nervous, you can (discuss the coping skills they can use).”
Acknowledge your child’s frustrations or anger without giving in to them or responding based on your own anxiety. “I understand you are unhappy right now, and that is okay. We still need to go to gymnastics because spending time with other kids your age and learning new skills is important. I know you can do it! If you are upset with me and need time to calm down, here are some things you can do.”
After you answer a few questions and convey confidence, move on. Endless talk and conversation about your child’s fears can keep the worry alive and ever-present. It also may convey to them that you are just as anxious as they are. Consider that less is more in this situation. Returning to routine daily activities sends the message to your child that you are calm and confident; therefore, they can trust that the situation is safe for them to participate in.
If there is a reasonable accommodation that you feel is necessary and helpful to support their bravery, consider offering this. How do you decide if an accommodation is helpful or excessive? Generally, accommodations that lead to more avoidance or less independence will work against you and your child’s goals. But accommodations that allow the child to take new steps and brave actions they have never taken before may be helpful to start. Accommodations should always be phased out over time.
When it is time for the goodbye, keep it brief and positive. Trust that the other providers can lead and engage with your child. They will be better able to do so once you have left the room. Drop-off at an activity is not the time for extended talks, long hugs, and the continued focus on how wonderful it feels to hold Mommy and Daddy! Quick transitions help the child focus on what is interesting and exciting about the new activity, moving their focus away from Mom or Dad.
Treatment Options
If the consistent application of the above strategies does not alleviate your child’s separation fears, and the behaviors are causing significant distress to you and your child, consider getting professional support. Treating SAD opens the door to new opportunities, helps the child learn new coping and life skills, and reduces the risk for later behavioral or emotional problems.
There is a wealth of evidence that Cognitive Behavioral Therapy (CBT) (including exposure practice) improves the symptoms and impairment associated with SAD. CBT educates parents and children on the cycle of anxiety and the factors that maintain it, provides skills training for parents and coping skills for youth, and for older children, teaches cognitive strategies.
The exposure portion of CBT involves systematic, collaborative, and gradual challenges to new situations and people to practice regulating and tolerating emotions, correcting faulty assumptions about the fear, and building self-confidence. A task or situation's safety and developmental appropriateness must always be considered before starting a bravery exercise. Scaffolding tasks, providing some support, and removing support slowly over time, are all necessary parts of helping a child learn to face their fears.
In addition, for young children, a treatment called Parent-Child Interaction Therapy (PCIT) has been adapted to treat children with SAD. This approach teaches parents skills to increase attachment and improve interaction patterns with their anxious children. It works to help parents increase warmth and responsiveness and reduce critical or invalidating commentary. Parents are educated in skills to handle interactions during separation situations and encourage brave behaviors. A randomized controlled trial of PCIT for SAD demonstrated that most children (73%) no longer met criteria for SAD post-treatment. This improvement was maintained at follow-up.
Addressing separation anxiety early allows the child and family to participate in life fully. It helps the child develop critical emotion regulation and coping skills to handle life’s challenges. And it relieves the family of the burden of being bossed around by anxiety.
