Separation Anxiety and Over-anxious Disorder

Separation Anxiety is completely normal in very young children. Once a child has developed the ability to remember the face of its mother (or mother substitute),it will respond to different faces with various levels of alarm because it cannot assimilate the new image with mother which is the child’s prime focus; this usually occurs somewhere between the ages of six and nine months.

Separation Anxiety tends to be at its peak somewhere between nine and eighteen months.  This, as the name implies, means times when the infant perceives itself as separated from the mother and unable to do anything that will bring the mother back into proximity.  It can occur again around two when the child becomes aware that it is free to determine its own action and that it is somewhat independent of the parent.

Most parents work out some kind of coping strategy at such times.  This might involve discussing the separation beforehand, explaining its duration. (Probably detailing the need for it is inappropriate as very young children have little perception of other people’s needs surpassing their own).  Once at the place of separation a parent might stay for a while until the child has become used to the environment and then may leave a favourite toy or his or her soft blanket, if the child has developed that attachment.  The parent’s anxiety at the time will also have an effect on the child’s ability to deal with the separation, as will traumatic events in the immediate past.

On the subject of trauma, Separation Anxiety can reoccur in later stages of a child’s life at times of stress such as a death in the family, chronic illness, divorce or separation or moving (Zwick & Israeloff).  It can also happen when a child goes off to college, where it will be called homesickness.  In this situation, if the child’s anxiety persists for more than four weeks, interferes with normal activities, is accompanied by several of the symptoms mentioned below, and the child is under eighteen, the problem might be diagnosable as Separation Anxiety, (Madsen). (Due to some diagnostic classifications, occurrence after the age of eighteen would require the disorder to be called something else.)

The ICD-10 Classification of Mental and Behavioural Disorders offers the following Diagnostic Guidelines for Separation Anxiety;

The key diagnostic feature is a focused excessive anxiety concerning separation from those individuals to whom the child is attached (usually parents or other family members), that is not merely part of a generalized anxiety about multiple situations. The anxiety may take the form of:

• an unrealistic, preoccupying worry about possible harm befalling major attachments figures or a fear that they will leave and not return;
• an unrealistic, preoccupying worry that some untoward event, such as the child being lost, kidnapped, admitted to hospital, or killed, will separate him or her from a major attachment figure;
  
• persistent reluctance or refusal to go to school because of a fear of separation (rather than for other reasons such as fear about events at school);
  
• persistent reluctance or refusal to go to sleep without being near or next to a major attachment figure;
  
• persistent inappropriate fear of being alone, or otherwise without the major attachment figure, at home during the day;
  repeated nightmares about separation;
  
• repeated occurrence of physical symptoms(nausea, stomach ache, headache, vomiting, etc.) on occasions that involve separation from a major attachment figure, such as leaving home to go to school;
  
• excessive, recurrent distress (as shown by anxiety, crying, tantrums, misery, apathy, or social withdrawal) in anticipation of, during, or immediately following, separation from a major attachment figure.

‘Many situations that involve separation also involve other potential stressors or sources of anxiety. The diagnosis rests on the demonstration that the common element giving rise to anxiety in the various situations is the circumstance of separation from a major attachment figure.’(IMH)

Research suggests that Separation Anxiety affects 4-9% of children at anyone time. DSM-IV says that among those seeking treatment it is equally split between boys and girls, while community surveys suggests far more girls are affected; possibly twice as many girls as boys (Xtra).  It may be that boys are more resistant to discussing this kind of problem. In Anxiety Care’s experience, boys are suffering more before they seek help, or are taken to help providers by their families.  It might then be possible to theorise that boys in treatment are more disabled by the disorder than girls in treatment,although there is no research available on this subject.

Xtra discusses risk factors in the generation of anxiety disorders in children.  These include, as mentioned above, traumatic events; also passivity and shyness;a temperament that shows fear and withdrawal in new and unfamiliar situations;insecure attachment between the care-giver and the child; anxiety problems,particularly agoraphobia, in a parent; coming from an extremely close-knit family.

Anxiety Care has encountered many adults, suffering from anxiety disorders that are affected by social situations and feeling unsafe, who have been brought up to be wary of ‘outsiders’ (which might be any non-blood relative) or who have inherited anxiety from their parents. ‘Inherited’ in this case might be a genetic predisposition or simply recognising a parent’s fear in certain situations.

One client reports being sent away on two occasions as a young child and finding, on his return, that first his grandfather and then his grandmother had ‘gone away’ with no explanation given by his parents for the loss of his beloved grandparents.  He further states that being sent away for a third time (a surprise holiday with an uncle), when only his parents and sister were left in the household, generated so much anxiety and so much mistrust in his parents that this ostensibly pleasant event stands out as one of the most traumatic and pivotal episodes of his childhood.

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Overanxious Disorder (OAD)

This disorder, more commonly known as Generalized Anxiety Disorder (GAD) in adults, (see the leaflet about GAD on this site) is also common in children.  For a diagnosis of OAD the child must experience excessive anxiety and worry, occurring more days than not over at least a six-month period, and it should involve a number of situations, be hard to control and involve at least one of the following symptoms: restlessness, rapid fatigue, mind wandering or blanking, irritability, (over response to stimulation), tense muscles, sleep problems such as difficulty falling or staying asleep or restless unsatisfying sleep. The anxiety, worry or physical symptoms must cause clinically significant distress or reduction of normal day-by-day functioning.

Brown states that about one-third of children with this disorder meet the diagnostic criteria for concurrent major depression.  He also offers a list of symptoms which might suggest OAD in a young person:

• Worries unrealistically about future events
• Is unrealistically worried about the appropriateness of past behaviours
• Is overly anxious about social behaviour
• Is concerned about his or her own competence
• Is a perfectionist
• Has spontaneous physical complaints not linked to specific situations such as generally not feeling well, headaches,stomach aches, or back aches
• Displays marked self-consciousness
• Has difficulty speaking in group settings such as school
• Is embarrassed when the centre of conversation or attention, even when positive
• Excessively and repeatedly seeks assurance
• Displays generalized tension
• Is unable to relax
• Exhibits nervous habits such as nail biting, hair pulling or foot tapping
• Refuses or is reluctant to attend school
• Avoids age-appropriate performance activities such as sports, games or playing with others
• Has obsessive self-doubt
• Acts and appears older than chronological age
• Wants to excel in multiple areas such as academically, athletically and socially
• Is seen as a ‘worry wart’and is usually quiet and well behaved
• May have a long history of problems
• May meet the diagnostic criteria for phobic disorder and/or depression.

Anxiety Care has encountered children who become very focused on perceived judgement by peers or family members,and when Separation Anxiety is also present this has involved mixed fear sand anger about the primary care-giver.  When the sufferer is a teenager there is, of course, a grey area where normal developmental stages of being critical of a parent or siblings, wanting to be alone and being hyper-sensitive to perceived criticism or being thwarted will overlap, perhaps presenting as extreme versions of normal self-involvement.

AW suggests that this disorder is more common in eldest children, in small better-off families, and in families where there is concern about achievement even when the child functions at an adequate or superior level; also that there is evidence to suggest that OAD is more common in families where the mother has an anxiety disorder.

Like all anxiety problems, the situation may be complicated by the presence of more than one diagnosable disorder.  With OAD these might be: Separation Anxiety Disorder as mentioned above, Obsessive/compulsive Disorder, Social Anxiety Disorder or Simple Phobia.  School refusing may also become a prominent difficulty and this might be to do with SAD or OAD as both are likely to involve situations that put the child under pressure.  In Anxiety Care’s experience, anyone who is constantly stressed by anxiety becomes super-sensitive to, and unwilling to cope with, life pressures.  This can result in the child (in sheer self-defence) laying down rules for his or her life that are extremely restrictive, not only for the child but for the whole family. These might include being unwilling to do certain things or to go to certain places or be around certain people.  Coupling this with the normal developmental stages that the child will be in can make everyone’s life very difficult.

This area of what is and what isn’t ‘normal’ anxiety and phobia for a child needs to be approached with caution.  Many anxiety problems of childhood might be seen as just exaggerated versions of what is normal for that child at that time (Harvard MSMHL), while others might be very different. Some fears such as that of snakes and spiders and high places seem to be natural to us as a species.  However, there are fears that are common to certain ages. Research, predominantly that of Schachter&McCauley (reported by Gebeke), and Marks, offers a range of these fears:

• 2-4 year-olds have fear of animals, loud noises, being left alone, inconsistent discipline, toilet training, bath,bedtime, monsters and ghosts, bed wetting, disabled people, death and injury.
• 4-6 year-olds have fear of darkness,imaginary creatures, animals, bedtime, monsters and ghosts, loss of a parent,death and injury, and divorce.

• 8 year-olds will probably have fragments of earlier fears but additional ones will tend to be more rationally based and will possibly include fear being late for school, social rejection, criticism,new situations, adoption, burglars, personal danger and war.
• 9 and 10 year-olds are also likely to fear divorce, personal danger and war and these three are very likely to continue as fear problems into the mid teens.  This age group might also fear blood and injury.
• 11 and 12 year-olds might fear animals,kidnapping, being alone in the dark and injections.  Marks states that beyond this age boys lose their fears more readily than girls.
• 13 year-olds seem to fear heights as well as the three mentioned above.
• 14-16 year-olds will tend to have a wide range of rational or almost rational fears which might include: injury, kidnapping,being alone in the dark, injections, heights, terrorism, plane or car crashes,sexual relations, drug use, public speaking, school performance, crowds,gossip and divorce. 

These childhood fears are not that different from those of adults and Schachter& McCauley list the most normally feared situations for adults as: public speaking, making mistakes, failure, disapproval, rejection, angry people,being alone, darkness, dentists, injections, hospitals, taking tests, open wounds and blood, police, dogs, spiders and deformed people.

As will be noted from the above,many childhood problems wax and wane as a normal part of development and a sensitivity in a certain area might be aggravated by a current problem so that this particular child temporarily ‘falls back’ into an earlier level of fear.  However, with SAD and OAD it has been suggested that psychological and social development might have a significant impact on which disorder is present.  That is, a child aligned to SAD will worry about the parent or other attachment figure disappearing and will be clingy and focused heavily on help-seeking, while the OAD aligned child will be more concerned about personal inadequacy and rational fears.

It has been suggested (perhaps unkindly)that a rule of thumb might be that, where the parent is concerned,the SAD child worries about not being looked after while the OAD child worries about the parent’s well-being.

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References and source material:

Adoption World Inc., ‘Special Needs Anxiety Disorders of Childhoodor Adolescence
http://adoptionworld.org/awi/corp/sn/snpage9.htm

Allen, JE, Helping Children Overcome Fears, HE-169, Purdue University, CooperativeExtension Service, West Lafayette, IN 47907
http://www.agcom.purdue.edu/AgCom/Pubs/HE/HE-169.html

Brown, Waln K. Ph.D, At-Risk Youth Desk, ‘Do You Know The Symptomsof Overanxious Disorder?’
http://www.consultnews.com/html/articles/weekly/waln98_3.html

DSM-IV, A Report of The Surgeon General. ‘Excerpts on Anxiety Disorders from Mental Health’
http://www.adaa.org/excerpts.htm

Deb Gebeke, Children and Fear, HE-458 (Revised0, November 1993
http://www.ext.nodak.edu/extpubs/yf/famsci/he458w.htm

Generalized Anxiety Disorder; Diagnostic Criteria
http://www.meantalhealth.com/dis1/p21-an07.html

Generalized Anxiety Disorder/Overanxious Disorder of Childhood
http://campus.Houghton.edu/depts/psychology/abn6/tsld016.htm

The Harvard Medical School Mental Health Letter, August 1988, Childhood FearsAnd Anxieties.
Http://www.accg.net/childfear.htm

Internet Mental Health (IMH), ‘Separation Anxiety: European Description’

The ICD-10 Classification of Mental and Behavioural Disorders

World Health Organization, Geneva 1992
http://www.mentalhealth.com/icd/p22-ch03.html

Madsen, Iben. ‘Separation Anxiety Disorder at University’
http://www.wis.edu/dateline/oct99/dtru01.asp

Marks, IM (1987) Fears, Phobias and Rituals. Oxford University Press

Westenberg, PM, ‘Separation anxiety and overanxious disorders; relations to age and level of psychosocial maturity’

Journal of the American Academy of Child and Adolescent Psychiatry, August 1999
http://www.findarticles.com/cf_0/m2250/8_38/55438316/print.jhtml

Xtra, ‘Separation Anxiety Disorder’, htt…/0,1733,1042- 77928,00.html+separation52Banxiety%2Bdisorder%2Bchildren&hl=e

Zwick, S. Psy.D & Israeloff, R. ‘Separation Anxiety’, ParentWatch-Article
http://www.parentwatch.com/content/art_print.asp/c=c_0153

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