Examining Separation Anxiety Disorder in Children

This great research paper on separation anxiety comes from Martha Nodar. Martha received a gift certificate to childtherapytoys.com for her submission. (And so can you!)

Some young children show signs of anxiety when separated from their parents for any period of time.  Mohacsy (1976) argues that children go through a process of slowly separating from their mother or primary caregiver, and begin to form their own individual self beginning approximately around “five months” and completing the process by “the third year of life” (p. 501).  Perez-Olivas, Stevenson, and Hadwin (2008) argue that separation anxiety disorder is one of the most common childhood disorders, particularly in children who are younger than 12 years old.  As described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, 2000), Separation Anxiety Disorder (SAD) (309.21) refers to pervasive and intense feelings of anxiety experienced as the result of being away from a familiar and primary caregiver especially after the third birthday.  

In most cases, the attached caregiver is the mother (Allen, Blatter-Meunier, Ursprung, & Schneider, 2010).  In order for the level of anxiety—as the result of the separation from the mother—to be categorized as a disorder, the manifested symptoms must meet certain criteria: feelings of anxiety must be above and beyond what is expected for the child’s developmental age, and must result in significant academic, social, and occupational impairment (DSM-IV-TR, 2000). Children who suffer from SAD are often diagnosed by health care practitioners when their behaviors start hindering their cognitive, social and academic skills.  It is worth mentioning that typically, children who are diagnosed with SAD as their primary disorder fall within the range of normative cognitive abilities.  Some children with special needs may have symptoms in similarity with SAD as the result of the comorbidity with their primary diagnosis, but SAD is not their primary diagnosis.  Multiple empirical studies have found a high correlation between a child’s development of SAD and maternal anxiety.  

How SAD Manifests

Manifestations of SAD in children younger than 16 years old may include an excessive insistence in knowing where the caregiver might be; constantly making telephone calls trying to get in touch with the attached important figure, and preoccupations with thoughts of death, accidents or illness of the caregiver and the idea that they may never see that person again (Dallaire & Weinraub, 2005).  Children who suffer from SAD may also worry about what possible harm may come to them in the absence of their mothers. Depending on their age and development, symptoms of SAD may manifest through the children’s inability to play in a room by themselves, avoiding visiting friends, struggling to focus on anything else, having nightmares, difficulty either falling or staying asleep, stomach problems such as nausea and vomiting, and having palpitations at the thought of being away from their mothers (Allen et al., 2010).  Although for many children these feelings of intense anxiety may start subsiding after they turn three years-old, for others, the intensity of the separation may continue or even worsen through the years (Dallaire & Weinraub, 2005).  These feelings may manifest in different ways depending on age, personality and circumstances bringing the scholars to research what may be the etiology of SAD.

Etiology of SAD

Recent research points to the notion that SAD may be triggered by a sequence of events that may begin during fetal development. Development refers to those changes occurring in collaboration with both heredity (nature) and the environment (nurture) (Santrock, 2011).  Fetal development involves changes that may happen to the fetus in the womb—which is considered part of the environment. Maternal stress during pregnancy, such as worrying about caring for a child, or having second thoughts about becoming a parent,  experiencing feelings of inadequacy about raising children, or apprehension about the relationship mothers may have with the father of their babies, are all environmental factors that may play a role in fetal development (Santrock, 2011).  In agreement with Santrock (2011), Lavallee et al. (2011) emphasizes that “maternal stress seems to influence . . . hormonal reactions and blood flow to the uterus influencing the development of the hypothalamic-pituitary adrenal axis in the fetus” (p. 355). 

Considered a major part of the neuroendocrine system, the hypothalamic-pituitary adrenal (HPA) axis is responsible for producing hormones, which are carried into the blood stream (Carlson, 2004).  The HPA axis facilitates a flow of communication and feedback between the hypothalamus (a structure in the brain responsible for stimulating hormones) and the pituitary gland (responsible for releasing hormones). The hypothalamus produces corticotrophin-releasing hormone (CRH) and delivers it to the adrenal glands where it is metabolized and secreted into the blood stream as cortisol, which helps the body adapt to stress (Carlson, 2004). These actions occur in consonance as the brain’s prevailing function is to balance itself.  

An over production of cortisol (by the adrenal glands) due to stress would inhibit both the hypothalamus and the pituitary gland from producing hormones. This means, the body’s natural resources (homeostasis) would be highly compromised. In other words, the extensive exposure to stress may render an individual’s nervous system inadequately prepared to cope with stress long term (Lavalle et al., 2011). A fetus consistently exposed to the over secretion of stress hormones as described above is more likely to be born with a susceptible nervous system. This is what it is called genetic predisposition, which begins in the womb and is impacted by the mother’s own level of anxiety during pregnancy (D’Amato et al., 2011; Lavallee et al., 2011).  Based on this data, D’ Amato et al. (2011) claim that the mother’s own anxiety is likely to play a major role in her children developing symptoms of separation anxiety. 

Arising from a similar paradigm, Perez-Olivas et al. (2008) claim that neuroticism (a personality trait), may be the mediating variable underpinning the mothers’ unconscious (out of conscious awareness) motivation to enhance their children’s propensity toward separation anxiety. Neuroticism shows up as emotional instability in interpersonal relations (Perez-Olivas et al., 2008). Feelings of shame, anxiety, guilt, low self-esteem typically accompany neuroticism.   In a move to seek evidence for their theories, Perez-Olivas et al. conducted an empirical, quantitative study in Britain with 129 children between six and 14 years of age and their mothers. Whereas the Revised Child Anxiety and Depression Scales-Child Version (2000) was the tool these researchers used with the children to assess symptoms of depression consistent with the DSM-IV-TR, the Five Minute Speech Sample was the tool applied to mothers to assess maternal over involvement and “self-sacrificing/over-protective behaviors” (Perez-Olivas, et al., 2008, p. 512).  Drawing from their findings, Perez-Olivas concluded that mothers with a propensity toward neuroticism also have a tendency toward anxiety—a major component of neuroticism.  Motivated to seek relief for their anxiety, mothers with this propensity tend to be overprotective of their children.  Overprotection “has been associated with enhanced levels of childhood separation anxiety” (Perez-Olivas et al., 2008, p. 510). 

Augmenting Perez-Olivas et al.’s (2008) arguments, Mills et al. (2007) propose that parental overprotection is not a sign of nurturing, but rather shows a tendency toward exerting psychological control over the children, which seems to be triggered by the parents’ own psychological instability.  It is important to distinguish between parental concern that falls within the normative range, and compensatory dysfunctional behavior, which is focused on the parents and attempts to mitigate the parent’s anxiety.  Parental overprotection is about protecting the parents from feelings of inadequacy, not about protecting the children (Mills et al., 2007).  By excessively worrying about their children’s safety (outside the normative range) the parents may be trying to cope with their own feelings of shame by shifting focus to their children (Mills et al., 2007).

Bradshaw (1988) defines this type of shame as “toxic shame” and suggests that toxic shame may be the cardinal feature of pathological behavior (p. 10).  Parents functioning within a toxic-shame framework are likely to view their children’s imperfections as a reflection on themselves and may unconsciously resent them as the result (Mills et al., 2007). Although some fathers may also overprotect their children, mothers are the most likely parents with that tendency.  Freud (1965), the founder of child psychoanalysis, emphasizes that “some mothers assign to the child a role in their own pathology and relate to the child on this basis, not on the basis of the child’s real needs” (p. 47).

Maternal Overprotection

In agreement with Freud (1965) and Mills et al. (2007), Levy (1943) argues that parental overprotection is most likely a futile attempt at protecting the parent from feelings of shame and guilt.  Levy’s operational definition of maternal overprotection includes the mother’s excessive interaction with her child to the point of preventing the child from developing as an independent person while trying to keep the child in an infantile state for as long as possible.  Levy categorizes a mother’s tendency toward overprotection of her child as falling under the realm of obsessional neurosis. Obsessional neurosis was a term first used by Freud (1926) early in his career.  Admitting being somewhat mystified by it, Freud suggests that the goal of obsessional neurosis is to ultimately prevent conscious awareness of unacceptable thoughts related to the past in a futile attempt to avoid or mitigate feelings of anxiety.    

In concert with Freud (1926) and while studying the mothers’ own histories and family of origin, Levy (1943) detected negligence, lack of emotional support and nurturing deficits in the way these mothers were raised themselves. These findings led Levy to suggest the probability of a multigenerational impact of insecure attachment in the family system of overprotective mothers. In other words, the mother’s tendency toward overprotection of her child may have begun long before the mother became pregnant with her child. Some researchers such as Dallaire and Weinraub (2005) argue that “Bowlby’s theory of attachment provides a theoretical framework to understand the etiology of separation anxiety” (p. 394).  

Bowlby’s (1969) attachment theory may shed light on the multigenerational effect of compromised attachment suggested by Levy (1943), and Dallaire and Weinraub (2005).  Dallaire and Weinraub assert that the type of attachment (secure vs. insecure) within the parent-child dyad is a good indicator of whether or not there is a presence of SAD observed in the children’s behavior. Attachment refers to the emotional bond infants tend to develop with their primary caregivers, which may have a tendency toward secure or insecure with both dynamics existing on a continuum (Bowlby, 1969).  Insecure attachment may include anxious, avoidant, and ambivalent bonding for the most part.  Insecure attachment manifests itself as either absent or inconsistent emotional availability to significant others in one’s life most of the time (Bowlby, 1969).  

Driven to investigate the probability that a child may develop SAD as the result of an insecurely-attached parent-child dyad, Dallaire and Weinraub (2005) led a longitudinal, quantitative, empirical study in an effort to isolate the predictors of SAD by the time the child is six years old and ready to start school. Dellaire and Weinraub recruited 95 participants of diverse ethnic and educational backgrounds including Caucasian, African-Americans, Hispanic-Americans and Asian-Americans mothers who had just given birth.  Their study began when the children were one month old followed by a regular schedule until the children were six years old.  As a corollary, in addition to observations in the children’s and mothers’ natural environment, the researchers used the Strange Situation procedure (Ainsworth & Bell, 1970) with the mothers.  Mothers of infants completed the Infant Temperatment Questionnaire.  The Child Puppet Interview was used with the children when they reached the age of six years old.   

Based on the results, Dallaire and Weinraub (2005) concluded that “infant-mother attachment insecurity during infancy predicted elevated levels of separation anxiety at age 6 years” (p. 403).  Furthermore, these researchers contend that their findings are “consistent with the literature linking” SAD in children with unresponsive childcare from the primary caregiver (Dallaire & Weinraub, 2005, p. 404).  Unresponsive childcare means the caregivers fail to appropriately and consistently meet the children’s needs most of the time (Bowlby, 1969). This data is significant because most children start attending school when they are six years old.  Refusing to go to school may become problematic and thus, may prompt parents to bring the child to a healthcare practitioner for assessment unaware of their own role in their child’s separation anxiety disorder.

Assessing/Diagnosing SAD

There are a number of instruments used to assess SAD, such as the Multidimensional Anxiety Scale for Children; the Screen for Child-Related Anxiety Disorders, the National Institute of Mental Health Diagnostic Interview for Children and Youth, and the Revised Child Anxiety and Depression Scales-child version. These tools are self-reports given to children in an attempt to assess the presence, degree, and intensity of the minors’ anxiety level as the result of being separated from their primarily attached caregivers. When children are too young to answer the questionnaire, the parents are then given the Revised Child Anxiety and Depression Scales-parent version to answer questions on behalf of their children.  

Striving to gain a better understanding of the children’s phenomenological response to the separation from their mothers, Allen et al. (2010) designed an anxiety daily diary for children over eight years old called Separation Anxiety Daily Diary-children version which assesses whether the children’s SAD may be triggered by the parent-child separation.  To test the efficacy of this instrument, Allen et al. (2010) conducted an empirical, quantitative study using descriptive data with 58 European children ages ranging from seven to 14 years old.  Allen et al. were eager to implement this tool to compensate for what they believe to be a low agreement rate between the older children’s self-reports on separation and anxiety and their mothers’ self-reports on their perception of their children’s separation anxiety.  Freud (1965) emphasizes on the importance of assessing both the mother and her child to discern the mother’s “pathogenic influence on the child” (p. 46).  Allen et al. concluded based on their findings, that for the most part, the children’s compliance with their daily diaries was high enough for the data to be useful to their hypothesis, which shows a correlation between the mothers’ anxiety and their children’s propensity toward SAD.  Once an assessment has been completed, the next step is usually intervention.

Treatment

For the treatment of SAD to have an opportunity to be successful it must encompass treating both the primary caregiver who tends to be the mother, and her children.  Freud (1926) argues that the first line of treatment for modifying adult personality traits, such as neuroticism must involve a psychoanalysis-based intervention.  Psychoanalysis is a type of insight-oriented therapy grounded in intellectual understanding and emotional acceptance.  Furthermore, the prevailing agenda of psychoanalysis is to bring the unconscious material to conscious awareness, which is expected to produce resistance in clients. Resistance is particularly expected from those who engage in toxic-shame.

Freud (1926) argues that “resistance presupposes. . . anticathexis” (p. 83).  This means that resistance is rooted in the individual’s investment of psychic energy in self-serving biases, such as self-deceptions.  Self-deceptions are the basis of a client’s defense system, which may be activated to preclude early experiences from reaching consciousness (Freud, 1926).  Parents may be motivated to keep themselves from learning the role they may be playing in their children’s SAD.  Treating the child’s SAD and the parent’s propensity toward anxiety and self-deception may also include sandplay therapy as a complement to psychoanalytic-based treatment.

Sandplay Therapy

Compelled to find a way to address the human tendency toward self-deception, Jung (1954) introduced the creative arts into his practice in an effort to by-pass the propensity of clients to self-edit their stories. A form of creative arts that is gaining momentum both with children as well as with adults is sandplay.  Coined by Jungian analyst Kalff (1980), sandplay is a form of play therapy using a tray with sand and analyzing the play under Jung’s (1954) theories.  Sandplay may be used with adults and children six years old and older.  Sandplay is nondirective, intuitive, metaphorical, and focuses on the sandplayer’s internal processes which are believed to be enacted in the sand (Bradway & McCoard, 1997).  

Sandplay therapy involves the sandplayer creating a scene in the sand and having the opportunity to express feelings about the scene. Depending on the miniatures used, the location of the figurines, and the sandplayer’s nonverbal communication, the counselor may begin to form conjectures in regard to what may be happening in the sandplayer’s internal world.  Bradway and McCoard (1997) argue that the entire tray represents the sandplayer’s unconscious. The sand itself represents a safe haven and facilitates the process (Bradway & McCoard, 1997).  Bradway and McCoard (1997) submit that children, especially boys who are between six and eight years old tend to use animals, especially prehistoric animals, such as dinosaurs, in their trays.  Riveting with metaphors, a crocodile, for example, when placed in close proximity to another, more gentle miniature representing the child, may symbolize a child’s perception of a devouring mother (Chevalier & Gheerbrant, 1969).  Any depicted towers in the sand may represent anger (Bradway & McCoard, 1997).  It is worth noting that while Sandplay and Sandtray may be used interchangeably, there are important differences. Sandplay was developed by Kalff (1971), and Sandtray was developed by Lowenfeld (1939). Sandplay is based on Jungian’s theories. Sandtray may be used applying  Jung’s approach, and also the humanistic, and the cognitive –behavioral approaches, or an eclectic integration.     

Discussion

Empirical data presented herewith points to the notion that mothers who engage in overprotection may feel inadequate for reasons of their own that date back to their own childhood in their family of origin.  Intervention offers parents an opportunity to consciously acknowledge and begin to heal their early wounds. Findings presented in this paper have implications for marriage and family counselors. It is incumbent upon these counselors to dig deep into the parent-child dyad and not simply accept what they may find at the surface—the presenting problem may be a disguise of the real problem in the family.  

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