SEPARATION ANXIETY IN CHILDREN AND TEENS

OVERVIEW

Some children experience fear or panic when they think about going to school in the morning. These children may tell their parents that they feel nauseous or have a headache, or may exaggerate minor physical complaints as an excuse not to go to school. When the child or adolescent exhibits a developmentally inappropriate and excessive anxiety concerning separation from their home or from those to whom they are attached, they may be experiencing a Separation Anxiety Disorder. Separation Anxiety Disorder is characterized by the child exhibiting three or more of the following for a period of more than four weeks:

1. recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated
2. persistent and excessive worry about losing, or about possible harm befalling, major attachment figures
3. persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped)
4. persistent reluctance or refusal to go to school or elsewhere because of fear of separation
5. persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings
6. persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home
7. repeated nightmares involving the theme of separation
8. repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated

As with Panic Disorder, separation anxiety is most likely to emerge during stressful times associated with major transitions such as entering elementary school or switching to middle school. It is also more likely to occur following an extended amount of time with the parent (such as being home for weeks on vacation, a holiday break, or following a lengthy time at home due to illness). In some cases, separation anxiety may emerge following a major trauma in the child's life, such as the death of a family member or a move to a new neighborhood and school. And as noted in the section on PANDAS, some children or teenagers might have sudden-onset or acute worsening of separation anxiety following an infection, even a mild or short-lived one.

In addition to the symptoms described above, children with an unreasonable fear of school may also:

• feel unsafe staying in a room by themselves and frequently go check to find their parent or have a need to be able to see their parent (e.g., a teenager in a shopping mall who feels a lot of distress if they can't always see their parent may be exhibiting a symptom of separation anxiety)
• display clinging behavior
• have difficulty going to sleep
• have nightmares about being separated from their parent(s)
• have exaggerated, unrealistic fears of animals, monster, burglars
• fear being alone in the dark, or
• have severe tantrums when forced to go to school

Separation Anxiety Disorder may be a precursor of other anxiety disorders in adulthood, and early recognition and treatment are important to prevent the development of Panic Disorder and Agoraphobia.

IMPACT OF SEPARATION ANXIETY DISORDER

Separation Anxiety Disorder can be exhausting and frustrating for the parents to deal with, but it is worse for the child who feels such intense fear and discomfort about going to school. If parents are unable to get the child to school, the child may develop serious educational, emotional, and social problems. As we saw with Panic Disorder, Separation Anxiety Disorder is also associated with an increased risk of Major Depression.

Because the anxiety is about separating from the parent (or attachment object), once the child or teens get to school, they usually calm down and are OK. It's getting them there that is the real challenge.

SCHOOL REFUSAL

Separation Anxiety Disorder can result in a child avoiding or refusing to go to school, but the terms "Separation Anxiety Disorder" and "School refusal" are not synonymous, as the latter is not a formal diagnosis. That said, children and teenagers who exhibit school refusal often suffer from significant emotional distress, most notably anxiety and depression. The most common diagnoses associated with school refusal are separation anxiety, social phobia, simple phobia, panic disorder, post-traumatic stress disorder, major depressive disorder, dysthymia, and adjustment disorder. In one recent study looking at school refusal vs. truancy, anxious school refusal was associated with depression and separation anxiety disorder, while pure truancy was associated with oppositional defiant disorder, conduct disorder, and depression. In those cases where both anxious school refusal and truancy were exhibited, almost 90% of cases had a psychiatric disorder, with increased rates of emotional and behavior disorders.

School avoidance or school refusal may serve different functions in different children or teenagers. For some children or teens, it may be the avoidance of specific fears or phobias triggered in the school setting (e.g., fear of school bathrooms due to contamination fears associated with Obsessive-Compulsive Disorder, or fear of test-taking). For other children or teenagers, it may serve to help them avoid or escape negative social situations (e.g., being bullied by peers, or having a very critical teacher). School avoidance or refusal can also serve to (temporarily) reduce separation anxiety, or to avoid settings that might be associated with panic attacks, or to gain attention for any somatic complaints (e.g., "Mommy, I can't go to school because my tummy hurts!"). In one study of school refusal, anxiety-related diagnoses were correlated more with negatively reinforced school refusal behavior (i.e., avoidance behavior), while separation anxiety disorder was associated more with attention-seeking behavior. Oppositional defiant disorder and conduct disorder were associated more with pursuit of tangible reinforcement outside of school.

When school refusal is anxiety-related, allowing the child to stay home only worsens the symptoms over time, and getting the child back into school as quickly as possible is one of the factors that is associated with more positive outcomes. To do that, however, requires a multimodal approach that involves the student's physician, a mental health professional, the parents, the student, and the school team. The same therapeutic modalities that are effective with Panic Disorder and Obsessive-Compulsive Disorder are also effective for school refusal, namely, exposure-response prevention (a form of cogntive-behavior therapy that may include relaxation training, cognitive alterations, and a graded hierarchy of steps towards the goal).

There is some research that suggests that education support therapy may be as effective as exposure therapy for treating school refusal. Working with the school psychologist, the student talks about their fears and is educated in the differences between fear, anxiety, and phobias. They learn to recognize the physical symptoms that are associated with each of these states and are given information to help them overcome their fears about attending school. The student is usually asked to keep a daily diary where they record their fears, thoughts (cognitions), strategies, and feelings about going to school. The time of day that they arrived at school is also recorded, and the record is reviewed each morning with the school psychologist. Although it might seem like a good idea to incorporate positive reinforcement for school attendance, that may backfire and merely increase the student's stress levels and anxiety.

Parent training in strategies to work with the child in the home is also an important piece of any school-based plan to deal with the student with school refusal.

Throughout this web site, I have included reasonable accommodations for different conditions, but when it comes to school refusal, accommodating the child by letting them stay home is generally contraindicated, unless there are other issues.

Dr. Rachel Klein of the NYU Child Study Center has provided some good tips to share with your student's parents, including:

• Do not deny the child's anxiety or worries, but acknowledge them and reassure him/her. For example: "I know you're worried I won't be there to pick you up, but there's no reason to worry. I'll be there."
• Try to find ways to enable the child to go to school. For example, a child is likely to feel reassured if times are set for him or her to call the mother from school. In extreme cases, mothers may stay with the child in school, but for a specified length of time which is gradually reduced.
• It is most important to tell the child exactly what s/he is to expect. There should be no "tricks" or surprises. For example, a child may be told that he should try to stay in school for only one hour, but after the hour he is encouraged or asked to stay longer either by the school or parent. This will backfire. The child will eventually refuse future arrangements for fear that they will be modified arbitrarily. Part of being anxious is anxiety about the unknown and the “what if?”.
• Punishment does not work, but kind, consistent, rational pressure and encouragement do.
• Do not quiz the child about why s/he feels scared. The child often does not know why. By not being able to provide an explanation, in addition to being anxious, the child feels guilty about not making sense of what is happening. Better to acknowledge that the fears make no sense and that the child has to fight them.
• Be open to hearing about how your child feels. However, lengthy discussions about the child's problems are not always helpful and can be experienced as a burden by the child. The focus must always be that you want to help your child be free of worries and fears.
• A child's reluctance to go to school can be irritating to parents. Expressing resentment and anger is counterproductive. And you won't feel the urge to do so if you adopt specific strategies to assist your child.

Other strategies or tips for students with separation anxiety are provided in another article by Dr. Wagner on this web site.