Separation Anxiety Disorder

Two independent measurements agreeing that closely means school refusal is not a complication of this condition. It is most of how the condition presents, and a child kept off school is the population the diagnosis is largely drawn from.

When separation anxiety stops being ordinary development

Separation anxiety is a normal developmental phase, commonest in infants and small children between about six months and three years, and the material is firm that it signals healthy cognitive maturation rather than a developing behavioural problem.

The disorder is the excessive version, and it is defined against the child's own developmental level rather than against an absolute standard. The American Psychiatric Association describes an excessive display of fear and distress at separation from home or from a specific attachment figure, atypical for the expected level and age, running from anticipatory uneasiness to full anxiety.

The duration criteria differ by age. In children the problem must persist at least four weeks and appear before eighteen. In adults DSM-5 asks for six months, which is a comparatively recent change: the diagnosis can now be made in adults at all.

What separation anxiety looks like at the door

The academic descriptions are unusually concrete. A child may protest on arrival, cling so tightly that a parent cannot detach, and scream and cry in a way that sounds like pain. The crying may continue for several minutes to upwards of an hour after the parent has gone, with other children and teachers refused and their attention rejected. Underneath it is a need to know where the parent is and that they are all right.

The reason this compounds is arithmetic rather than psychological. As the child falls further behind in coursework, returning becomes harder, so the short-term costs, poor or declining performance, alienation from peers and conflict at home, feed the avoidance that produced them.

At home the symptoms persist in a familiar setting. The child may be frightened to be in a room alone even knowing the parent is next door, may fear going to sleep in a dark room, may refuse sleep unless the parent is visible, and may shadow the parent through the day.

What triggers separation anxiety in adults

Avoidance carries into adulthood, and the workplace consequences are measured rather than assumed: partial working days, more total absences, and holding back on carrying tasks through.

The stressors DSM-5 names for young adults are all ordinary life events rather than misfortunes:

• leaving the parental home
• entering a romantic relationship
• becoming a parent

For anyone, onset most often follows a stressful event, and the list runs from the loss of a loved one or a pet through parental divorce, a change of school or neighbourhood, and natural disasters, to any circumstance forcing separation from an attachment figure. Parental overprotectiveness is associated with it in some cases.

How Freud and Bowlby explained separation anxiety

The disorder's origins sit in attachment theory, and two versions of it.

Freud's account has infants with instinctual impulses that traumatise them when unnoticed. The infant learns that the mother's absence is followed by a distressing lack of gratification, so absence becomes a conditioned stimulus for anxiety, and the child comes to fear every situation involving distance from the caregiver.

John Bowlby's framework is about proximity. Infants are instinctively motivated to seek a familiar caregiver, particularly when alarmed, expecting emotional support and protection. All infants attach; how they attach differs, and Bowlby set out four styles. The one relevant here is anxious-ambivalent attachment, in which an infant is extremely distressed by the caregiver's absence and is not reassured by their return.

Not reassured by their return is the phrase worth keeping. It describes a fear that the caregiver's presence does not switch off.

How separation anxiety runs in families

Heritability was estimated at seventy-three per cent in a community sample of six-year-old twins, with higher rates in girls. That is a high figure for an anxiety condition.

Temperament contributes through three named routes:

• behaviourally inhibited temperaments, meaning timidity and anxiety in unfamiliar places or with unfamiliar people
• low effortful control and self-regulation
• high negative affect

In adults, negative temperament predicted higher levels of separation anxiety.

Daniel Schechter and colleagues examined the other side of the relationship, in mothers with their own histories of maltreatment and disturbed attachment. Their responses to ordinary social bids from infants and toddlers were linked to their own maternal post-traumatic stress disorder and depression, and those atypical responses have been associated with separation anxiety in the child. The physiological correlates were measured: disturbed maternal stress response to separation, and lower activity in the medial prefrontal cortex when mothers with post-traumatic stress disorder watched video of themselves separating from their own toddlers.

Low socioeconomic status contributes as well, by raising parental depression.

Why the neurology of separation anxiety is called preliminary

Preliminary evidence associates heightened amygdala activity with the symptoms, and defects in the ventrolateral and dorsomedial areas of the prefrontal cortex correlate with anxiety disorders in children generally.

Preliminary is the source's own word, and it is used here rather than removed.