Hello brave parents and caregivers,
It is common for parents to struggle to help children with separation anxiety. And it can be so heart-wrenching. On the one hand, you know it’s important for your child to make new friends and enjoy experiences outside your home, while on the other, it’s so tough not to scoop him back up and take him with you when he clings to you as you say your good-byes.
Separation anxiety is developmentally normal and usually diminishes as a child matures, typically around the age of 3-years-old. I distinctly remember the tearful “mama!”s after dropping my daughter off to her 2-year-old school program. I deeply felt the tension: I knew it was important for my daughter to gain mastery of navigating her environment without me; but I felt terrible walking away from her.
Separation Anxiety versus Separation Anxiety Disorder
While separation anxiety is normal in early childhood, persistent distress upon separation inappropriate for a child’s age or developmental level may be separation anxiety disorder. Separation anxiety disorder is the most commonly diagnosed and impairing childhood anxiety disorder; because it can lead to avoidance of experiences necessary for favorable development, it has the potential to disrupt a child’s social and emotional functioning.
What is Separation Anxiety Disorder?
Separation anxiety disorder is “developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached”.
Children with separation anxiety disorder worry about harm befalling an attachment figure or experiencing an untoward event that could lead to separation. Also, they are reluctant or unwilling to go out, go to school, or to sleep alone; they fear being alone, and may experience nightmares about separation and/or physical symptoms like headaches or stomachaches leading up to or at the time of separation.
What Causes Separation Anxiety Disorder?
Like most mental health conditions, separation anxiety disorder develops from an interaction between biology and environment. Genetics plays a role, as does a child’s temperament. Environment can also be influential. For instance, an overprotective or authoritarian parenting style that prevents a child from achieving a sense of mastery over age-appropriate activities or from participating in her own decision-making communicates that she not capable of navigating her environment, which may lead to the development of anxiety. On the other hand, well-supported parental guidance that fosters a sense of autonomy builds a child’s confidence in her capabilities and strengthens her resilience to the development of separation anxiety disorder.
The Effects of Separation Anxiety Disorder
A common feature of separation anxiety disorder is avoidance, which for families is often very challenging. A child who fears something terrible will happen if he is separated from a parent may struggle to participate in activities such as sports or dance. Or, he may resist going to school. Avoiding participation in developmentally-appropriate activities with peers may impair a child’s social-emotional development.
Physical Symptoms and Sleep Problems
Physical symptoms, such as headaches and stomachaches, are another common feature of separation anxiety disorder. They may crop up in anticipation of or at the time of separation; they can be related to true physical distress or an attempt at avoidance. Children with separation anxiety disorder may struggle with bedtime including experiencing nightmares or having difficulty sleeping alone—both of which may impact sleep.
Separation-related distress can bring up conflicting emotions for parents— “I need to leave for work, but omg he’s so upset (Am I a terrible mother if I go to work?)… but I really need to go, I’m going to be late for a meeting, but…”. This can be stressful. To alleviate a child’s distress, parents may make accommodations like forgoing going out to avoid leaving the child with a sitter, impacting their quality of life.
Treatment of Separation Anxiety Disorder
Keep in mind that separation anxiety disorder may not be a phase. Around one-third of children with untreated separation anxiety disorder will go on to experience it in adolescence and adulthood. Also, there is some evidence suggesting that childhood separation anxiety disorder is associated with other anxiety and depressive disorders in adolescence and adulthood, including panic disorder and agoraphobia.
So, if you suspect your child is experiencing separation anxiety disorder, what should you do? An assessment with your pediatrician is a good place to start, particularly if your child reports physical symptoms —it’s a good idea to rule out potential medical causes.
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) is the mainstay of treatment for separation anxiety disorder; it is based on cognitive restructuring, exposure, and relaxation techniques.
Lavallee and Schneider’s What to Do When You Don’t Want to Be Apart: A Kid’s Guide to Overcoming Separation Anxiety is a workbook based on CBT tenets that is designed for parents and children to complete together. It teaches kids about their scared feelings, educates about how to reframe anxious thoughts (e.g., my mom might get hurt while she is out) into more realistic thoughts (e.g., my mom will have a nice time out at dinner with her friend) and offers exposure lessons to help kids practice separating from their parents.
What is Exposure-Based Therapy?
When I was a doctor-in-training, I worked with a distraught family whose son with separation anxiety disorder struggled to go to school. Struggling to know how to help, I met with my supervising doctor who offered only one recommendation: Help him get back to school as soon as possible.
Um, okay, easier said than done. But he was right. Avoiding anxiety-provoking situations again and again causes anxiety to grow. Exposure-based therapy can be instrumental in breaking this cycle. So how does it work?
It goes something like this:
- A child and parent work together on a “bravery ladder” by listing separation situations that are anxiety-provoking, from least scary (e.g., being across the room from mom for 5 minutes) to most scary (e.g., spending the night at Grandma’s house).
- With the help of his parents, the child practices these situations one “rung” at a time using relaxation techniques and cognitive restructuring to help him along the way.
- With practice, he learns that he is capable of managing in an environment without his parents and that his fears are unlikely to be realized. As a result, separation becomes easier and easier.
What to Do When You Don’t Want to Be Apart: A Kid’s Guide to Overcoming Separation Anxiety offers a child-friendly approach to exposure exercises to help kids with separation anxiety (with one caveat: planning a special dinner is suggested as a reward; I’m not one to connect food with rewards. If you’re interested in learning why, please read here: How to Talk to Kids About Food.)
Though these CBT techniques may help provide guidance for parents trying to help their kids with separation anxiety disorder, they are not a substitute for formal participation in therapy.
Practical Tips to Alleviate Separation Anxiety
Separation anxiety is different from separation anxiety disorder– it is a developmentally normal phase that diminishes as a child matures. That said, CBT techniques (and What to Do When You Don’t Want to Be Apart: A Kid’s Guide to Overcoming Separation Anxiety) may be useful in helping children with separation anxiety.
These tips may also be helpful:
1. Validate your child’s worried feelings about separation. After all, your child loves and depends on you more than anyone; it’s only natural she should feel anxious about being apart from you.
2. Develop a succinct good-bye routine. Practice it before using it at separation time. For example: a hug, an “I love you” and a “I’ll see you soon”. It is helpful to separate when the routine is complete.. Prolonging the good-bye with added hugs and kisses may make separation more difficult.
3. Remind your child often that mom and dad always comes back.
4. Read Karst’s The Invisible String or Penn’s The Kissing Hand with your child. These books help children to understand that they’re always connected to the ones they love, even if they are not physically together.
5. Remain mindful of your own anxiety ( we’ve all been there!). Prolonged or emotional good-byes may communicate to your child that there is indeed something to worry about when she is away from you. Try to project calm and confidence at separation time, even if you don’t feel that way.
6. If possible, create opportunities for other trusted adults to watch your children every so often. If it makes you anxious for other adults to watch your child, it may help to start with small steps, like a trusted grandparent or baby-sitter playing with your child in a separate room while you’re home. The more a child grows accustomed to being cared for by other loving adults, the easier it will be for her to be away from you.
7. Reinforce (safe) instances when your child takes the initiative to separate from you. For example, if she decides to walk away from you to grab a new book at the library (while remaining within your eyesight) provide her with labeled praise for getting her own book without your help.
8. Engage your child in positive talk. Talk to her about how fun it is to learn new things at school or how cool it is to play hide-and-seek with her baby-sitter.
9. Avoid “sneaking” away when your child is occupied with something else. This may erode trust.
10. Continue to communicate your unconditional love and support. Strengthen your relationship through intentional connection (5 minutes of special play time per day can be helpful). Knowing she has a safe base to return to will increase your child’s confidence when it comes to separating from you.
11. Make a visual schedule. Velcro pictures or photographs of the main parts of your child’s day (e.g., breakfast, lunch, nap, play time, etc.) to a piece of poster board, making the last picture on the schedule yours. Your child can remove each one as that time passes. When she reaches your picture, it signals that it is the time of day when you pick her up or return home. A visual schedule empowers a child by providing a sense of time, consistency, and predictability.
Brave parents and caregivers,
Separation anxiety can be a challenging phase in a child’s development. Your love and understanding will help support your child as he becomes more comfortable separating from you—and the skills he gains along the way will help to build his confidence and sense of self.
Until next time,
Ehrenreich JT, Santucci LC, Weiner CL (2008). Separation anxiety disorder in youth: Phenomenology, assessment, and treatment. Psicol Conductual. 16 (3): 389-412.