Separation anxiety disorder (SAD) is commonly diagnosed in children, with average onset at the age of 6 years old. (Battaglia et al., 2016). Current research agrees that parental intrusiveness and overinvolvement is one of the leading triggers for SAD in children who are already vulnerable to anxiety disorders ((Gar and Hudson, 2008; Wood, 2006; Brumariu and Kerns, 2010; Hudson and Rapee, 2001). Based on Erik Erikson’s psychosocial stages of development theory, recommendations are grounded in the goal of helping children with SAD assert their growing independence to eliminate the fear of separation from attachment figures.
What is Separation Anxiety Disorder?
Between 5% and 20% of children experience anxiety, with between 4% and 8% of children suffering from separation anxiety disorder (Masi, Mucci, and Millepiedi, 2001; Battaglia et al., 2016). While most anxiety disorders impact primarily white, middle-class individuals, between 50% and 75% of those with separation anxiety disorder come from low socioeconomic status (SES) homes (Masi, Mucci, and Millepiedi, 2001). SAD is most often seen in middle childhood, with average onset at 6 years old. Symptoms usually subside by adolescence (Battaglia et al., 2016).
SAD is categorized by excessive anxiety about separation from attachment figures, anticipatory anxiety, and avoidant behavior. Of those diagnosed with SAD, 75% show symptoms of school refusal, a form of avoidant behavior (Masi, Mucci, and Millepiedi, 2001). The American Psychological Association (“What are Anxiety Disorders?”, 2017) defines SAD as being excessively fearful about separation from those with whom an individual is attached that is out of proportion to situation or age inappropriate and that hinders an individual’s ability to function normally, persistent for 4 or more weeks in children and for 6 or more months in adults. While some physiological separation anxiety is adaptive and evolutionarily beneficial, common in most mammals, SAD reaches the point of dysfunction, with more exaggerated duration and intensity than physiological separation anxiety (Battaglia et al., 2016).
Children who suffer from SAD are at risk for adverse long-term effects. SAD is positively associated with lifetime diagnoses of two or more adult anxiety disorders. There is strong correlation between childhood SAD and adult obsessive-compulsive disorder and social phobia, with weaker but still significant correlation between childhood SAD and adult panic disorder (Lipsitz et al., 1994). SAD may also impact educational attainment, as many children suffering from SAD have difficulty attending school or concentrating in class, due to the fear of what is happening to their loved ones outside of the classroom (Masi, Mucci, and Millepiedi, 2001).
Summary of Current Literature
Battaglia and colleagues (2016) determined that important factors for early onset separation anxiety in preschool years include maternal smoking, low maternal education, maternal depression, maternal overprotection, low SES, parent unemployment, and parental divorce. This conclusion coincides with the current knowledge concerning separation anxiety disorder – specifically the influence of maternal overprotection and SAD. Wood (2006) hypothesized that children who already exhibited anxious tendencies would exhibit more symptoms of SAD if parents are highly intrusive in daily routines and activities. The study found that intrusiveness is positively associated with SAD, with weaker correlations to other anxiety disorders such as obsessive-compulsive disorder. Intense fear over separation may be exhibited for multiple reasons. Firstly, the child of an intrusive parent will have had few experiences with independent action with their parent and feels no level of mastery, control, or self-efficacy. Therefore, they are fearful when a parent is not there to intervene on their behalf. Secondly, the child of an intrusive parent may have been negatively reinforced to avoid separation. For example, it is developmentally normal for a young child to cry when initially separated from their parent. However, if the parent immediately returns to remove the child from a stressful situation, the child will not learn how to calm themselves or function without a parent near.
Wood (2006) found no relation between parental intrusiveness and parental anxiety disorders. Gar and Hudson (2008) concur with Wood’s (2006) findings, arguing that mothers of anxious children are more involved than mothers of non-anxious children, regardless of maternal anxiety status. Although previous literature suggested that anxiety of the parent leads to a dysfunctional parenting style that teaches the child to be more sensitive towards threat and perception of danger, as well as elevated parental sensitivity towards child’s distress, emerging literature disagrees (Last et al., 1987). Mothers of anxious children tend to be more overprotective, nonobjective, self-sacrificing, and critical than mothers of non-anxious children, yet the status of mothers’ own anxiety is not associated with the aforementioned qualities of the mothers of anxious children (Gar and Hudson, 2008; Wood, 2006; Brumariu and Kerns, 2010).
As previously stated, children diagnosed with SAD already have high levels of arousal and emotionality, putting them at higher risk for developing a variety anxiety disorders (Hudson and Rapee, 2001). In the case of genetic vulnerability, increased parental involvement and protection may reinforce this vulnerability, reduce the child’s perceived control over potential threats, and increase avoidance of threats. Rejecting parenting, including being less supportive, less promoting of independence, and giving more help than the child needs, has been previously associated with behavior disorders, depression, substance use, eating disorders, and schizophrenia. Emerging literature suggests that mothers of anxious children were far more negative than mothers of non-anxious children, offering more criticism and less praise when observing their child having difficulty completing a task. However, in studies that followed Hudson and Rapee’s (2001) original study, research indicates that there is a weaker association between child anxiousness and maternal rejection than there is between parental control and child anxiousness (Gar and Hudson 2008). Therefore, one may conclude that while parental rejection is influential in the development of childhood anxiety disorders, it is not as influential as parental overinvolvement.
Quality of Evidence
Current literature largely concurs concerning the prevalence of and reasons for childhood SAD. As past literature is recognized as incorrect, new literature replicates studies regarding the impacts of parent intrusiveness on the development of child anxiety disorders. For example, Last and colleagues (1987) suggested that parental anxiety levels would have a negative impact on their ability to rear their children. Multiple recent studies state the opposite, finding no significant link between parental anxiety and SAD (Hudson and Rapee 2001; Gar and Hudson 2008; Wood 2006). However, the link between negative parenting and SAD is unclear, requiring future research. Current literature disagrees on the true impact of negative parenting on childhood anxiety, as it is being associated with depression more strongly than anxiety.
Unfortunately, research on this topic is not culturally generalizable. Although Wood (2006) was able to find a racially diverse population for his study through a convenience sample, Gar and Hudson (2008) studied primarily Caucasian and middle-class participants. As previously stated, a majority of children with SAD are from low SES homes (Masi, Mucci, and Millepiedi, 2001). Although Wood (2006) and Gar and Hudson (2008) came to similar results concerning parental intrusiveness and parental anxiety disorders, the combination of one study utilizing a convenience sample and the other utilizing a non-diverse population means that their results lack generalizability. The cultural implications for the relationship between intrusiveness and SAD are unclear and need further research. For example, research suggests that behavioral, cognitive, linguistic, and motivational deficits seen in minority and immigrant children are methods of adaption to the dominant culture (Coll and Szalacha, 2004). With this in mind, SAD in children of color may be a maladaptive way of ensuring family ties remain strong and stable. More research is needed with children and families of color and with low SES for a more generalizable understanding of SAD.
Theory Identification and Description
Erikson’s theory of psychosocial development states that when a crisis is experienced during any such stage, an individual must be able to overcome that crisis to move forward with their development (Erikson, 1950). The goal, according to Erikson (1968), is to resolve a presented crisis by developing positive qualities. Failure to complete a stage of development does not halt future development, but may make it difficult to successfully complete future stages. Past stages and crises may be resolved at a later time. Erikson (1950) outlined eight stages of development. The first four stages – Trust vs Mistrust, Autonomy vs Shame or Doubt, Initiative vs Guilt, and Industry vs Inferiority – are more relevant to the experience of SAD than the later stages, as SAD is primarily a childhood experience. A brief description of these stages follows.
The first stage of development is Trust vs Mistrust (Erikson, 1950). Experienced during the first year and a half of life, the individual is learning how to respond to the world around them. Through forming attachments, an infant is taught to trust or not trust the world around them. Inconsistent or harsh child-rearing styles may lead to a delay in this stage. The goal in Trust vs Mistrust is to develop the positive quality of hope.
Stage 2 is known as Autonomy vs Shame or Doubt. Between 18 months and 3 years of age, toddlers begin to assert their independence (Erikson, 1950). The individual needs supportive parental figures to assist in teaching their child “self-control without a loss of self-esteem” by providing an environment where it is okay to fail yet providing enough assistance so that constant failure is avoided (Gross and Humphreys, 1992). The goal in Autonomy vs Shame or Doubt is the quality of will (Erikson, 1950).
Stage 3 focuses on Initiative vs Guilt between the ages of 3 and 5 years old (Erikson, 1950). As most children in the United States begin pre-school during this time, children are given increased opportunities to develop interpersonal skills with their peers during this time and learn self-initiative. However, if a child’s independence is hindered during this time, they may begin to feel like a nuisance to others and develop feelings of guilt. A healthy amount of guilt is necessary to learn self-control but too much may lead to low self-esteem. The goal of this stage is to develop the positive quality of purpose.
The fourth stage of Erikson’s psychosocial development is Industry or Competence vs Inferiority (Erikson, 1950). Between the ages of 5 and 12 years old, children begin the feel the need to accomplish specific competencies that are valued by their social stratosphere and feel a sense of pride when these competencies are successfully accomplished. However, if deterred by negative parents or teachers, the child may begin to doubt their own abilities and develop a sense of inferiority. Yet, with no failure a child will not develop a sense of modesty. A healthy balance between industry and modesty will lead to the positive quality of competence.
Interpretation and Implications
During the first 18 months of life, infants are attempting to determine the answer to one question – is the world safe? If their interactions provide reliability, care, and affection, infants will develop a sense of trust (Erikson, 1950). However, if a child is exposed to negative or rejecting parenting, they will be unsure of whom to trust and become distressed. Erikson’s theory on the stages of development implies that unhealthy attachments in infancy may lead to the feeling of being unable to control the situations around them later in life, a symptom of childhood SAD (Wood 2006).
Between 18 months and 3 years of age, a toddler begins to assert their independence. It is critical that they are allowed to explore their own limits during this time, allowing them to feed and clothe themselves to the best of their ability so they may learn new skills and conquer new challenges (Erikson, 1950). However, children diagnosed with SAD often have overprotective and intrusive parents (Hudson and Rapee 2001; Gar and Hudson 2008; Wood 2006). Without these early experiences of exploration, success, and failure, an individual will not learn self-efficacy or self-esteem. Instead, they will become overly dependent on others and feel inadequate in their own ability to survive in the world (Erikson, 1968). This stage in Erikson’s theory suggests that SAD is exasperated by few experiences of independent success in a safe or comfortable environment before reaching school age, where onset of SAD is most likely to occur (Wood 2006; Masi, Mucci, and Millepiedi, 2001).
During the years a child attends pre-school or kindergarten, the individual is learning skills of initiative and leadership through independent social interaction with their peers. When supported in their exploration of this new setting, the child learns about their ability to lead or make decisions. However, as aforementioned, if a child’s attempt at independence in this stage is blockaded, the child will develop a sense of guilt and become slow to interact with others (Erikson, 1968). It therefore may be reasonable to conclude based on Erikson’s psychosocial theory of development that intrusive parenting leads the child to believe that they do not have control over situations around them (Wood, 2006; Erikson, 1950). A child who has not successfully conquered the crisis of Initiative vs Guilt may believe that they are a nuisance to others and not take steps to initiate social interactions, only feeling comfortable when their attachment figure is near, leading to SAD.
Industry during middle childhood is not stopped by restricting independence, such as in previous stages of Erikson’s (1950) theory. Instead, a child will not feel confident in their abilities if criticized or does not receive proper encouragement from parents and teachers. By the time SAD symptoms begin to exhibit, around the age of 6, the child has already been told during stages 1 – 3 of Erikson’s stages of development that independence is an unwise choice (Masi, Mucci, and Millepiedi, 2001). If they continue to be told this during the stage of Industry vs Inferiority, they will begin to doubt their own abilities. Just as they doubt the safety of their world in Trust vs Mistrust, doubt their ability to survive in the world during Autonomy vs Doubt, and fear interactions with their peers during Initiative vs Guilt, the child with SAD will feel no level of mastery, control, or self-efficacy during Industry vs Inferiority (Wood, 2006; Erikson, 1950; Gar and Hudson 2008; Hudson and Rapee 2001).
Erikson’s theory implies that SAD is triggered by the compounded effect of a lifetime of restricted independence. Children with SAD, according to this interpretation, have not had the support needed to feel confident in their own abilities and become extremely distressed when separated from the attachment figure upon whom they depend for the completion simple and difficult tasks. Parental intrusiveness and overprotectiveness may stunt the emotional development of a child, resulting in the child feeling that the world is an unsafe and unpredictable place which they cannot navigate by themselves when asked to during middle childhood. SAD occurs most often during the stage Industry vs Inferiority because it is the first time for many children that they have been forced to be in an environment for an extended period without their attachment figure. They are not used to having to function independently without an intrusive parent critiquing their actions and become distraught without the constant negativity to which they have become accustomed.
Professional Point of View
The Program Director of King Open Extended Day (KOED) in Cambridge, Massachusetts, Bucky O’Hare, agreed with the aforementioned research findings (B. O’Hare, July 20, 2017). KOED provides after-school services to a diverse group of children from many different racial, cultural, social, and economic backgrounds. Bucky stated that his biggest task in the beginning of a new school year is helping parents of pre-school students to let go. “I know it’s a difficult transition for a family, but kids are taking their cue from [their parents]”, Bucky said concerning parental intrusiveness and separation anxiety. He went on to muse about children he has known over his 15-year tenure at KOED that had a more difficult time than others leaving their parents, not just the children he worked with that had been diagnosed with SAD, affirming that a majority of children he knew who had difficulty separating from their parents to attend school had a lower level of independence and self-efficacy than students who excelled in new social situations.
However, Bucky was concerned over the quality of evidence and diversity of populations studied. He brought up a specific case of a family in Cambridge that recently immigrated from the Dominican Republic. This family has been through multiple traumatic experiences and their three children have a variety of special needs. The youngest daughter, a recent kindergarten graduate, frequently has melt-downs which impact her functioning in school. She is unable to calm down until she hears her mother’s voice on the phone. Neither mother, father, nor step-father are overly intrusive in their children’s lives. Bucky does not believe this student’s separation anxiety is caused by over-intrusive parenting, rather by traumatic experiences at a young age. He expressed his desire for more generalizable research, citing the Tuskegee Syphilis Experiment as a reason that there is not more research conducted with minority populations (“U.S Public Health Service Syphilis Study at Tuskegee”, 2016).
Recommendations – The Road to Independence
To help a child with SAD with their fear of separation and improve their social interactions, the early stages of Erikson’s (1950) psychosocial stages of development theory must be addressed. As previously stated, Erikson’s theory suggests that SAD is caused by the compounded effect of not reaching the goal of each stage of development before the SAD average onset age of 6 (Masi, Mucci, and Millepiedi, 2001). Both parent and child must relearn how to interact with one another until the symptoms of SAD have subsided and functioning has returned to an age appropriate level. The following recommendations are to help a child with SAD assert independence and complete any stage of development that may have been stunted due to parent intrusiveness.
The goal of Trust vs Mistrust is Hope (Erikson, 1950). To develop the quality of Hope, parents and children should perform age appropriate tasks, such as puzzles or mazes, together. The Social Worker present will give the parent explicit instructions how ways to be supportive and offer encouragement to their child without becoming overbearing. This activity focuses on rearing-style, teaching the parent how to offer reliable, affectionate, and caring support to their child. The child will learn, through multiple exposures to this task, that their parent is a safe base and learn a new answer to the question “Is the world a safe place?”. By addressing parenting rearing-style, this recommendation hopes to lay a new foundation for the relationship between parent and child.
The goal of Autonomy vs Shame or Doubt is to develop the quality of Will, defined as “the faculty by which a person decides on and initiates action” (Erikson, 1950; “Definition of Will in English”, 2017). It is important during this stage for the child to experience success in independent actions. To begin, parents should allow their child to make small decisions at home that are appropriate for their age group. For example, an overly intrusive parent may lay out clothes for their child to put on every morning. Being able to control such a seemingly small part of their day may make a difference in their development and feelings of control over the world around them for children with SAD. Even if the child chooses to wear stripes, polka dots, and a rain coat on a sunny day, it is recommended the parents praise their child’s creativity and independence in this activity.
The goal for Initiative vs Guilt is Purpose (Erikson, 1950). To give the child a sense of control and self-efficacy, they should be given more chores around their home. The child may be upset at first because they are accustomed to their parents doing all the housework or giving very specific instructions on how tasks should be completed. Parents may explain this change in the home to their child by letting the child know that their contributions are valued and they are an important member of the family. To allow the child to develop a sense of purpose in their family and household, age appropriate tasks should be given to the child. After the tasks is completed, each time the child does the task without being asked or reminded, or if the child’s level of skill at this task improves, the parents should verbally recognize their child for this improvement. Through constant and consistent praise and encouragement, the child may begin to step outside of their comfort zone and see other ways they are able to contribute to the world around them. This task will increase their sense of purpose and their feelings of control of the world around them.
The goal of Industry vs Inferiority is Competency (Erikson, 1950). To help the child develop new skills and competencies, the parent and child should learn a new activity together. Not only will learning a new activity increase the child’s feelings of self-efficacy, it will also create a more secure bond between parent and child. If the parent does not already know how to complete a task, they may be less likely to over-correct their child. It is important for the parent in this situation to not be over critical of their child’s learning style or their own ability to learn a new skill. In this situation, the parent should offer verbal praise to themselves in front of their child, so the child may learn positive ways to address the self. The parent should also express the different ways that they are proud of their child in a new situation. Learning a new skill together may ease the child’s fear of new situations as they learn how to conquer a new challenge in a new way with their parent.
Unfortunately, although SAD impacts primarily families from low SES households, current research does not adequately address how SES impacts different families who have children struggling with anxiety disorders. Future research should seek to report on how SAD impacts families of different cultural, economic, and racial backgrounds. Recommendations for helping children with SAD are based from Erik Erikson’s psychosocial stages of development theory and focus on helping overly intrusive parents to repair their relationship with their child by offering the child more independence and support in a variety of situations.