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Mental Health

Separation Anxiety Disorder: School refusal


Jacquelyn Weatherall, M.Ed for Anxiety Canada


For most children attending school is an enjoyable and exciting experience. For some, however, attending school may be overwhelming and is endured or avoided. These children may suffer from separation anxiety disorder (SAD) which manifests as school refusal. Avoidance is a key component of SAD and can take the form of school refusal, reluctance to interact with other children without close proximity of parents or caregivers or refusal to sleep alone.

It is important to understand that separation fears are common at 8 months, 12 months and between 18 months and 3 years of age. Also it is typical for children to have separation fears when first entering day care or preschool. SAD, however, is characterized by excessive and developmentally inappropriate anxiety about being separated from home or significant caregiver.

Symptoms of SAD are physical, cognitive and behavioral. Physical symptoms may include stomach distress, (aches, nausea, diarrhea, vomiting), headaches, over heating, fatigue, crying, inability to speak, tantrums/occasional aggression and stubbornness/"entrenched" response. Cognitive symptoms include excessive, worrisome thoughts befalling either one's self or caregivers. These may include getting lost or kidnapped, fear of illness or worry that the caregiver may be involved in a dangerous or fatal accident and thus not return home. The connection among these varying thoughts is the fear that one will ultimately become separated from the primary caregiver. Behaviorally, the most common and disruptive symptom is school refusal. This may look like complete refusal to attend, attending but leaving early, starting late and tantruming upon arrival, attending but experiencing a high degree of distress. Other symptoms include refusal or reluctance to be alone or without caregivers, repeated nightmares with separation themes and avoidance of situations, which may result in separation from caregivers.

SAD is treatable and manageable when properly diagnosed. Parental involvement in treatment is critical, as the child needs to be rewarded with parent attention for success. The parents also need to be fully supported in keeping with the treatment plan, despite increasing pressure from the child to go back to the "old" ways of interaction.

The ideal length of time for treatment of SAD is about twelve sessions, although studies show that children who have as few as six sessions do show improvement. As with the treatment of other anxiety disorders it is recommended that each session stand alone and incorporates the core components of cognitive-behavioral therapy.

Treatment begins with educating the child about anxiety and normalizing its experience. Anxiety is a normal response experienced by all and helps to alert one to danger. Using the analogy of a faulty car alarm or smoke alarm that goes off at the slightest signal is helpful in having the child or youth realize when anxiety is no longer a useful tool in personal safety. Education also involves assisting the child to understand why anxiety develops. An ideal way to explain anxiety is to use the A (affect) B (behavior) C (cognition) triangle so the child can understand the relation ship between their thoughts ( C ), feelings (A) and behaviors (B).

For example a child may think (C ), "My dad is going to have a car accident if he goes to work," the feelings (A) are nausea and head- ache; the behaviors (B) are tantrums and complaints of illness so dad will stay home. Understanding this relationship ultimately empowers the child to take more control of the anxiety provoking situation.

The next core component of treatment is to help the child recognize the bodily sensations of anxiety, the feelings (A), and how to manage them. Learning to use the body sensations as a clue or warning sign of anxiety helps the child know when to use utilize effective management strategies such as progressive muscle relaxation or deep and controlled breathing.

Another core component of treatment is cognitive challenging or assisting the child to gain the ability to diffuse overwhelming and exaggerated thoughts (C ). Learning to identify unhelpful thoughts and externalizing them as "worry monsters," empowers the child to confront them. Other cognitive strategies help the child to replace disruptive thoughts with more helpful ones or realistically estimate the probability of the thoughts actually coming true. Identifying and then challenging faulty thinking patterns helps to minimize the hold anxiety can have and increases the likelihood of participation versus avoidance.

All the components of cognitive-behavioral treatment of anxiety disorders are important to successful intervention. However, exposure, or having the child face their fears is critical. Exposure is best done gradually, rather than an all or none, sink or swim approach. A hierarchy or fear ladder is constructed so that the child can gradually face the least fearful situation to the most fearful situation. As the child works through the fear hierarchy the length of exposure can also increase from brief to prolonged. Each hierarchy will be as individual as the child. For example, playing at a friend's house without a parent present may be precluded by having the parent in the house for all of the playtime, half of the playtime, or waiting outside in the car with cell phone access only.

Although SAD can be a stubborn disorder, it is treatable. Part of the core components of treatment includes understanding the likelihood of relapse. Often a child will do well for a period of time and then suddenly regress. This may occur when schedules and expected routines change. Knowing this is normal will help in reestablishing prior gains.

Research has shown that the cognitive-behavioral anxiety management skills and exposure strategies are effective in the treatment of Separation Anxiety Disorder. School like work for adults, is a vital part of a child's experience and growth. Learning to manage the debilitating symptoms of SAD empowers children and families to face their fears and lead more enjoyable lives.


About the author

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Thank you to Anxiety Canada's Registered Clinical Counsellor and Clinical Educator, Mark Antczak, for reviewing this resource in 2022.


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