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Separation anxiety treatment should address all of the factors that are contributing to a child’s anxiety. Every child is different; however, most of the time treatment is successful in overcoming separation anxiety. Let’s look at an example of the child below.
Sandy was a ten-year-old female who developed separation anxiety after her grandmother was hospitalized due to pneumonia. Sandy’s grandmother lived with her, her mother, father, and her two-year-old brother. Sandy spent three days out of school during this time due to mom’s hectic schedule. Sandy’s grandmother recovered fully and returned home. Soon after this, Sandy developed symptoms of physical illness every morning before school. On the days she did go to school, she would go to the nurse and tell her she didn’t feel well. She began having trouble sleeping in her own room and would often try to get into bed with her grandmother. She had always been a little anxious, but nothing like she was exhibiting since her grandmother's hospitalization. When Sandy’s mom brought her to therapy, she was not sure what was going on.
When Sandy first came she was a little worried about leaving her mom. I told her she could check on her mom, who was right outside the waiting room, any time she wanted. This seemed to make her feel better. The first two sessions she checked on her mom once, and after that she no longer checked on her. While talking and playing with Sandy it became obvious that she was experiencing separation anxiety. She worried almost daily about her parents and her grandmother dying. She indicated she had terrible physical symptoms, horrible thoughts of her mother getting hurt on the way to work, and a fear that her grandmother would fall out of bed. These symptoms were the worst in the morning and in the evening at bedtime. Sandy’s mother had no idea what to do. She vacillated between forcing her to do things and allowing her to stay home, depending on how much energy she had at any given time.
Can you imagine being a child experiencing these terrible thoughts and feelings? It’s no wonder children with separation anxiety fight so hard to avoid being away from their parents. They actually believe they or their parents may die if they are separated! They are terrified and feel unsafe at the idea of what may happen.
The goals of separation anxiety treatment are to replace these incorrect beliefs with accurate ones, to create situations where the child is safely able to confront their fears, and to work with the family to facilitate the development of new beliefs and feelings through new experiences.
Areas of Treatment
What’s Happening in Kids' Bodies When They Are Anxious?
Remember that separation anxiety treatment must target all of the contributing factors and components of the anxiety. The physical sensations that accompany anxiety are often the first clue for a child that they are getting anxious. Recognizing the physical sensations and thoughts that precede the anxiety is the first step in therapy. One of the first things I do with children who are anxious is to teach them how to tell when they are anxious. I may ask them what they are thinking, and feeling, and doing when they are worried about being separated from their mom and dad. I also will ask them how they feel in their body. It is almost always helpful to use art therapy with kids. It is easier for them to communicate their thoughts in pictures or through other art media, than it is to do so verbally. It’s also fun! They can draw a picture of themselves and color it in, with each color representing a feeling that they have in their body.
Because there is usually a physical component to anxiety, another important part of separation anxiety treatment is to teach kids how to relax their bodies. One way to do this is deep breathing. Essentially this is a way of inhaling and exhaling breath that helps to relax the body and mind. Kids can learn to do this when they feel tense, and experience almost an immediate sense of this anxiety subsiding as well as a sense of control! Often after doing this exercise, I will have the kids teach their parents how to do this. Then everyone can practice together. Muscle relaxation is another way to teach kids how to relax. I use a script that has kids pretend to be different animals stretching body parts or in different case scenarios such as squishing mud with their toes. This is fun and, like deep breathing, provides a sense of relaxation and control.
What Are Kids Thinking and Feeling When They Are Anxious?
Separation anxiety treatment focuses on interrupting the chain of events leading up to the worries. Throughout therapy, kids can continue to help us to figure out what they are experiencing. I may ask them to draw pictures of specific episodes of separation anxiety that they have had during the week. What were they thinking, feeling, and doing when they had the problems with their separation anxiety?
After this exercise we often will pull in parents and show them the work we did. This also helps parents to understand what is actually going on with their child. For example, one child drew a picture of everyone in the family dying in a car crash. This picture helped to illustrate for mom why she was having tantrums and fits each morning when going to school. Imagine if every day when you left for work, you had thoughts fears and visions about everyone in your family dying, and you believed it was really going to happen! I find it really helps to learn what’s going on in your child’s head.
Creating New Beliefs and Experiences
Separation anxiety treatment has to create alternatives to those scary visions, thoughts, and feelings kids are having. So, in the example above, we would draw a picture of the family happy in their respective work places. Then we would work on replacing those visions of the accident with positive visions of mom at her computer typing and smiling and feeling happy and safe. I might also ask the child to imagine feeling calm and peaceful instead of anxious, and we would repeat that exercise until the child indicated they felt that way. Working on the child’s actual thoughts is also an important part of treatment for separation anxiety. So instead of thinking “mom is in a car accident” the child would learn to replace that thought with “mom is in the office doing her work”.
When Is It Happening?
Separation anxiety treatment must also focus on when the separation anxiety is happening. For example, if the anxiety happens every morning before school, parents and kids can work extra hard to be aware of the anxiety and to make attempts to ease it. They can actually talk about what the child is experiencing, and sometimes this is enough to help.
If kids are not talking about anxiety, we may set up a chart to give them the incentive to do that. I use a lot of praise, and encourage parents to do the same, whenever kids identify or verbalize their feelings. If a child is struggling to share these feelings with a parent, we will reward them with a sticker when they do that, which they can cash in for a treat at the end of the day. Each stage children are able to master is a step towards overcoming separation anxiety. It’s important that they feel a great sense of accomplishment when they are doing this work.
There is always a family component to separation anxiety treatment. Parents have usually sought treatment because they feel like the anxiety has gone beyond what they know how to handle. If parents have restructured their life to accommodate their child’s anxiety, they need to stop doing that. Children who are not able to avoid the things that are making them anxious will never conquer that anxiety. It may get worse! I work with parents on finding a balance between pushing their child too hard or letting them escape too much. Successful attempts at overcoming anxiety must be met with a lot of parental praise and a reward.
Creating a Fear Hierarchy
One of my favorite things to do in separation anxiety treatment with kids is to create a fear hierarchy. Essentially this is a technique called gradual exposure. Kids are asked to list all of the things that are frightening to them, and then cut the list into strips and paste it in order from the least to most frightening. Then in therapy and at home we work on conquering those fears, until the worst imaginable fear is faced. Children are also asked to create a fear thermometer where they can rate their fears on a scale of one to ten. In this way, we can really measure progress. If the item that originally caused the child to feel a level 10 now causes them to feel a level 3, we know we are making progress!
Separation anxiety treatment usually will require some assistance from the school. You can see in the above example why it would be important for the school nurse to be aware of what a child is experiencing. In some cases, depending on the severity of the symptoms, you may need to implement actual interventions in school to assist the child in making it through the school day or focusing on their class work. Some parents are uncomfortable giving the school too much information. How much the school knows about your child’s anxiety really depends on the result of your weighing the pros and cons of giving them that information.