Article Information

Mariana Suciaghi*

Department of Anesthesiology and Intensive Care, Psychology, Emergency Clinical County Hospital, 540136 Târgu Mures, , Mures County, Romania

^*Corresponding Author: Suciaghi M, Psychology Cabinet, Sarmasel, str. Unirii, no. 1, Jud. Mures, Romania.

Received: 04 August 2022; Accepted: 05 October 2022; Published: 07 October 2022

Citation:

Suciaghi M. Separation Anxiety. Journal of Psychiatry and Psychiatric Disorders 6 (2022): 263-267.

Abstract

Keywords

Separation anxiety; Psycho-diagnostic; Cognitive processes

Article Details

1. Introduction

This paper contains general notions about separation anxiety: how it manifests, physiological symptoms, cognitive and emotional changes, intervention in separation anxiety (seven sessions plus a reevaluation), methods of intervention (relaxing techniques, therapeutic stories, role playing, desensitizing, exposure) and the two main objectives of the study:

1. Psycho-diagnostic and evaluation objectives: diagnosing cognitive processes and personality structures
2. Interventional objectives
3. Including the child in social and educational activities
4. Enhancing self-esteem by moral compensation

2. General Notions Related To Separation Anxiety

It is normal for a child to feel unsure or afraid when separated from parents or caretakers. Usually these feelings diminish in time, when the child gains more self-esteem. Separation anxiety is a normal adaptive response from the moment of birth until about the age of 4 as well as transition periods from home life to social life (kinder garden, school, first trips, camps, etc.). Usually the discomfort felt by the child if he or she is helped to calm down and his or her attention is redirected to other activities. If however this fear of separation persists over the age of 5 and it affects daily activities (refusing to go to school, to sleep alone, to sleep over at friend’s houses, to go on trips or to camp without the parents) than it is possible that he or she might be suffering of separation anxiety.

Separation anxiety is a frequent problem: approximately 12 % of children suffer from it before the age of 18. Taking in to account that about half of the children with anxiety disorders will continue to experience anxiety issues at an adult age, it is important for this problem to be noticed early and to seek help from a specialist.

Separation anxiety can severely interfere with the child’s life and restrict him or her in his or her daily activities. Social isolation, developmental difficulties and the inability to keep friends, refusing to go to school or difficulty of achieving good educational results are just a few of the problems associated with separation anxiety. Often children with separation anxiety appear to be sad, redrawn and indifferent.

The signs of onset of this disorder can manifest in 3 stages of life: between the ages of 5-6, 7-9 and 12-14 years.

3. How it Manifests?

Separation anxiety manifests itself through intense fear, followed by physiological changes (palpitation, rapid breathing, muscle tension, etc.) and behavioral changes (crying, hanging on to parents etc.), all of these as a response (reaction) to separation from parents or other important people in the child’s life. Sometimes this reaction can appear as a response to separation from a home (ex. leaving on vacation).

Symptoms of separation anxiety manifest themselves on a physiological, cognitive, emotional and behavioral level.

Physiological symptoms can be a good clue for parents for the purposes of identification of separation anxiety. Children and teenagers with these problems may complain of headaches, nausea, vomiting, stomach aches, dizziness, heart palpitations, increased or heavy breathing or other specific physical signs of anxiety. Usually these symptoms appear before or around the moment of separation and are absent when the child is with his or her parents – for example, they may appear in the morning when the child needs to go to school, but are absent in the weekend, when the child is at home.

On a cognitive level a series of worries and anxious thoughts appear, related to being separated and to being alone; some children of younger age can’t identify these worries or thoughts, but older children and teenagers say that they are afraid something bad is going to happen, either to them or to someone dear to them (parents or caretakers).

The most frequent worries of children who suffer from separation anxiety are:

1. What if something bad happens to my mom or dad?
2. What if my mom or dad forgets to pick me up from kinder garden or school?
3. What if I get lost and can’t get home?
4. What if somebody kidnaps me?
5. What if I get sick and my mom isn’t there to help me?

On an emotional level, these thoughts can provoke intense fear and uncertainty.

Small children manifest themselves with intense crying, screaming, rolling on the floor or hanging on to parents when they anticipate or go through the moment of separation. They have difficulty sleeping or sleeping alone and experience nightmares related to separation of even death of loved ones. Often children suffering from separation anxiety will say “Don’t leave me alone!”, “Where are you going?”, “Please don’t go!”, “I beg you, don’t leave me!”. They can also refuse to stay alone in a room, to stay at kinder garden or school or to participate in other activities (swimming, dancing, group activities etc.) in the absence of their parents.

Although separation anxiety is more common in children, teenagers can go through this as well, especially as a response to some changes (ex: moving to another city or school) or stressing situations (ex. parents divorcing or death of a loved one). Changes on a behavioral level:

1. The teenager refuses to go to school if a parent or somebody he or she trusts isn’t present
2. Refuses to sleep over at friend’s houses
3. Can’t go on trips or to camp without a parent
4. Refuses to use public transportation alone

4. What should be done? Intervention in Separation Anxiety

If you notice the earlier mentioned behavioral changes in your child or they are brought to your attention by a teacher or school counselor, address a specialist for a correct evaluation, he or she will collect data from you about the onset of the issue, it’s evolution, sustaining factors, symptoms and will establish an intervention plan together with your child.

Basic intervention principles in separation anxiety:

1. Parents play a crucial role in treating separation anxiety, in our experience, the level of motivation, implication and availability is the basis of a successful intervention.
2. The gold standard in treating separation anxiety, as well as other form of anxiety, is gradual exposure to feared situations, after creating a well-established hierarchy of these situations. The principles of an efficient exposure are the duration (the child must remain in the feared situation until he or she can sense the anxiety diminishing) and the frequency (to reduce the intensity of the anxiety, exposure must be daily in the beginning).
3. In the beginning the child will feel worse (exposure to the feared situation – separation – will trigger the enhancement of emotional discomfort and physical sensations), after which the situation will improve (intensity will decrease). It is important for the child but mostly for the parents to know these things in order to understand the therapeutic approach as well as the dynamic of the emotional and behavioral changes.
4. A structured and predictable environment, created by daily routines of the child (meals, hygiene, sleep, free time) enhance the level of control the child can have over current activities and events in his or her life, thus reducing uncertainty.
5. Validate the child’s feelings (“I understand that this is hard for you…”), this way making the child feel that you understand him or her and you are by their side. This also offers the child an alternative model to face anxiety: instead of rolling on the floor and screaming, he or she can express his or her feelings verbally. It is important not to ridicule the child’s feelings, or argue over this (“You are a coward!”, “I will get upset with you if you don’t stay in school!”) or minimize the experience (“This is stupid! There’s nothing to be afraid of! Nobody’s going to eat you!”). A supportive approach is much more effective.

Separation anxiety is one of the most frequent emotional problems in children and teenagers, it can be treated successfully with cognitive-behavioral intervention in collaboration with a therapist, the child and the parents.

5. Case Report

Basic information:K. age 7 years and 7 months, 1st grade student at Grupul Scolar Samuil Micu from Sarmasu.

5.2 Diagnostic and evaluation objectives: The evaluation of K.A. was solicited by her mother for the purposes of diagnosing cognitive and personality disorders. The mother expresses her concerns related to her youngest daughter (K), a 1^st grader, who ever since starting school cries daily, at school and at home, after talking to her dad on the internet, who is away for work in a foreign country. She is even crying during her dance lessons, which she started approximately a year ago.

5.3 Short description of psychological components (Table 1-6):

Table 1: Subjective level/Emotional (including satisfaction/quality of life).

Table 2: Cognitive level.

Table 3: Behavioral level.

Table 4: Physiological level.

Table 6: Interpersonal relationship level (including couple, family, group).

Clinical interview with the parents

6. Conclusion (the summary of information in psychological terms):

K accepts working together with ease, seems to understand instructions and doesn’t ask for further information. She lets me know she likes to draw a lot. She is relaxed, calm, stable and is concentrating on the task at hand. After the Raven test, we find an IQ of 104, an average intellect.

The family portrait lets us know that K socially and emotionally is curious, passionate about stories and games, she is trying to understand the feelings and needs of others. First she draws herself, hair, fingers, slippers, showing she has the sense of reality, but she doesn’t have any ears, hinting to a lack of communication with the rest of the family. The second person she draws is her older sister (B), they are holding hands, showing a strong bond between the two of them, but a lack of communication at the same time (the lack of ears). The age difference between the two girls is almost 7 years. The third person drawn is her mother, she erases a lot (anxiety), she manages hard to draw the hand holding her sister, after several tries she does, but she forgets to draw fingers. The fourth person drawn is the father, holding the mother’s hand. He is the largest in the drawing, K says the prettiest one as well, because he buys her everything she wants, the mother never having the money to do so.

While she is drawing, K tells us that her father is working in England on a truck, where he gets a lot of money and buys her everything she wants, but she misses him terribly, and wants him to come home, because she hasn’t seen him in a few months.

Worshipping her father can be seen in the enchanted family portrait as well (her father is depicted as a big bear) and in the desired family portrait, where all the family members are together and she is placed next to her father.

While she is drawing she confesses that what makes her cry all the time is “fear of loneliness”, for her mother not to leave and she remain alone.

K’s drawings reflected anxiety and the main issues of this:

1. Separation from her father
2. Fear of being abandoned by the mother as well
3. Diagnosis

• DSM – V-TR -Axa 1: 309.21-Anxietate de separare
• ICD 10: F 93.0-Angoasa de separare a copilariei

8. Recommendations (implications of the conclusions on the objective and evaluation):

- The counseling of the mother

- Game therapy with the objectives of:

1. Including the child in social and educational activities
2. Enhancing self-esteem with moral compensation

9. Intervention Plan:

It consisted of a number of seven sessions (in the first two weeks two sessions/week, the next two sessions were once/week and the last session after two weeks) plus a reevaluation session after six months.

1^st Session - objective: Reducing separation anxiety

To reduce separation anxiety (brought on by the father leaving for work) I started to emotionally prepare K for the encounter with her father, which was due in a month and a half. First I tried explaining to her that a month and a half isn’t that much time, it’s only six weeks, six times five days in which she has to go to school, it’s not that long, and it should be just enough to make him a surprise until he arrives home. Based on her passion for drawing I proposed to start a greeting card for him (taking in to account that it was near Christmas), every day another card, including the days she wasn’t attending any sessions, than we will put it in a nicely wrapped gift box , making it his Christmas present. She gladly accepted. I also explained to her that her father will be home for the holidays, together with the family, after which he will leave again, because they need the money to buy her nice things, keep them in school, keep the house nice, and that her mother’s paycheck can’t cover all that alone. From the discussion with the mother I found out that she is avoiding K when she’s lonely, and she never told her that she misses the father too. For this the task given to the mother was that every night the three of them get together and talk about how much they miss the father, how they feel and what they can do about it to make it easier on them. The first evening was the mother’s turn to talk and the girls to listen and try to come up with a solution. The next evening was the older daughter’s turn than the third evening was K’s turn. This exercise will help them communicate and understand each other better.

K’s mother also confesses that every evening after talking to the father on the phone and web-cam, although she promises not to cry to get gifts from him, after turning the webcam off, she starts crying for missing her dad, and the mother can’t manage to calm her down.

2^nd Session - objective: Relaxing the child

K brings me the drawings and greeting cards she made for her father. She tells me that occupying herself makes the time fly by faster and easier. She draws the desired family all together. We decide to show her father the drawings every evening and talk about her feelings. As homework she will have to fill out daily a chart to monitor her crying: a smiley face for every time she manages to resist the situation without crying and a sad face every time she fails. If at the end of the day she has more smileys than sad faces she will get a red heart and a small reward, and if she doesn’t she gets a dark cloud with tears. At an understanding with the mother she will get something she wants with a small material value, or they will do something together she likes. We learn relaxation techniques and I ask her to do them at home.

At the end of the session I talk to the mother, and set homework for her to: talk to the father in the absence of K and ask him not to promise K expensive toys but rather to tell her that he misses her as well, and let her know that knowing she is sad and crying only makes him more sad and homesick, risking even that he can’t pay enough attention to driving and have an accident, but if he knows that K’s calm it will be easier on him.

3^rd Session - objective: Enhancing trust and self-esteem

It seems the homework is paying off, the first evening she promised her father not to cry after they finished talking, but she still cried a little, the second day she didn’t cry at all, the third day she cried twice, but not because she was missing her father, but because of her mother, and although in the evening she felt like crying, she restrained herself. The next few days K manages not to cry after her father, she is focused on preparing his surprise. The mother confesses that sometimes K still cries when left at school or dance class.

We read and discuss a therapeutic story to enhance trust and self-esteem. We close with relaxation techniques and I tell her to do them at home as well.

4^th Session - objective: Revising knowledge obtained from previous sessions

Role playing: 2 puppets: one is an unhappy girl (mine) whose father is away working, and the other (hers) is happy and she tries to help the other one stop crying by teaching her what to do to forget about missing her dad. This way we manage to revise the lessons learned earlier.

We draw a greeting card for daddy.

As homework she keeps completing her chart, and because there is an upcoming dance competition, K is afraid to participate, the mother will ask the father to ask K to record the competition to show it to him in the evening to help with his homesickness.

5^th Session - objective: Fear management

Desensitizing: “fear of loneliness” – we play hopscotch with 9 boxes, each representing a negative feeling. For skipping from one to the other we will have to find for every negative feeling a positive one until we get to the top, at which point she will get rid of the fear.

Homework: she continues to complete the chart, draws greeting cards for the father and relaxation techniques.

6^th Session - Exposure - objective: Confronting the fear and enhancing self-esteem

Drawing of the dance competition, in the bleachers the father is present and he is very proud of her and she is happy. This exercise helps her increase his self-esteem and stimulates her to practice, thus participate in the competition, to be the best and show her father the recording.

7^th Session - objective: Revising the gathered knowledge and avoiding recurrence

The chart looks very good; K stopped crying when left at school or dance class or after talking to her father on the phone. She competed in the dance competition and was very happy for winning a medal for which her father told her how proud he was of her and can’t wait to see her. She seems to have understood the fact that he will come and leave again; she involves herself in school and extracurricular activities as well without the fear of her mother leaving. To be sure that K is mastering the situation I ask her to do one last drawing: “How to help the clown be happy?”, this having the same issues as she does.

K seems to have understood what she has to do and it isn’t hard for her to teach the clown. A favorable outcome in a short time was possible due to good communication with the mother and her involvement in the tasks at hand. The mother and the two daughters manage better with the distance separating them from the father, understand each other better and communicate.

After six months I have reevaluated K (family portrait, interview, observation, free discussion with K and the parents). In the family portrait everybody is happy, they have hands, feet, showing she has sense of reality, but they still don’t have ears (she smiles and tells me she forgot, showing affection).

It shows that K is a stable little girl, she stopped crying after her father when he’s away at work, she understands and waits for his return, she manages her time correctly and in accordance with her age, the results at school are very good, she keeps attending dance class, stopped crying after her mother.

A case successfully solved!.

References

1. psyclinic.ro