Distress resulting from separation from an attachment figure has been accepted as an attribute of normal infant development since the early part of this century (Bowlby, 1973; Freud, 1909/1955). Bowlby interpreted the distress that infants displayed to maternal separation as reflecting their anxiety at being left alone. Indeed, he saw fear of being left alone as the root cause of generalized human anxiety (Bowlby, 1973). In normal development, distress due to separation appears between the ages of 7 and 12 months and peaks around 15 to 18 months of age. This inverted U-shaped curve to the onset, peak, and diminution of distress to separation has been found across various cultures among which the pattern of rearing has varied considerably. For example, Fox (1977) found this pattern among infants raised on an Israeli kibbutz (where infants slept separately from their mothers and were cared for by a primary caregiver other than the mother). Barr, Konner, Bakeman, and Adamson (1991) reported a similar developmental function for infants raised among the !Kung bushmen in the Kalahari Desert, as did Kagan and Klein (1973) for infants raised in rural Guatemala. The common developmental change in separation distress across cultures most probably reflects universal changes in the infant's abilities to understand and represent its mother's disappearance from view. Thus, this behavior should not be considered as maladaptive but rather as a normative part of early development.
There are reports of individual differences in the tendency to display distress to separation. Davidson and Fox (1989), for example, reported a pattern of greater right frontal electroencephalogram (EEG) activation associated with a temperamental disposition to cry in response to maternal separation. Similar findings by Fox, Bell, and Jones (1992) suggest modest stability of frontal asymmetry over time.
Although normative changes in distress to separation find it diminishing around 18 to 24 months of age, instances of continued distress response to separation from mothers have been described in the child clinical literature. These instances were described under the heading of separation anxiety. Freud (1895/1959) first conceived of the concept of anxiety neurosis in 1895 and suggested that anxiety was a symptomatic consequence of a repressed libido. Only later, in 1926, did he begin to take note of separation anxiety. The psychoanalytic perspective viewed separation anxiety as a tendency for adults to experience apprehension after the loss of a significant other (Freud, 1926). Freud's later studies led him to conclude that anxiety was an emotion that resulted from the experience of traumatic events. Since that time, separation anxiety has been studied in a variety of contexts, including the attachment literature. It was not until the 1980s that separation anxiety was considered a discrete clinical diagnostic category. The Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III) designated separation anxiety disorder (SAD) as one of the three anxiety disorders of childhood and adolescence (American Psychiatric Association, 1980). Current diagnostic criteria of SAD include excessive anxiety with respect to separation from an attachment figure (most commonly the mother or primary caregiver) or separation from familiar surroundings such as home.
Children experiencing SAD may exhibit both behavioral and physiological symptoms such as extreme distress, terror, hyperventilation, or heart palpitations when anticipating separation. Children with SAD seek to avoid separation from attachment figures and, not surprisingly, are most commonly referred to clinicians as a result of a hesitancy or unwillingness to attend school. Similarly, both sleep disturbances and refusals to sleep are also characteristic of SAD.
Studies that examine comorbidity of psychiatric disorders indicate that children and adolescents with SAD are commonly diagnosed with other disorders as well. One half of children with SAD are diagnosed with other anxiety disorders, and one third are diagnosed with depression. It has been suggested that children with SAD may have become overly dependent on the attachment figure, often after a stressful life event such as illness or the loss of a loved one (Erickson, 1998). SAD occurs in approximately 2% to 4% of children and adolescents, and those with this disorder may be at increased risk for psychopathology in adulthood. Current treatment approaches to SAD include behavioral interventions, psychotherapy, and family interventions as well as psychopharmacological treatments.
The literature on childhood anxiety has recently emphasized the important influence of temperament factors (Kagan, Resnick, Clarke, Snidman, & Garcia-Coll, 1984) in this area. It has been found that the incidence of childhood anxiety disorders is greater in children who exhibit the temperamental characteristic of behavioral inhibition (Bie-derman et al., 1990). This characteristic, described as the tendency to withdraw from novel or social situations, may be related to separation anxiety.
Separation distress is a normative response across different caregiving and cultural contexts for infants to display distress on separation from the caregiver. This behavioral response appears during the second half of the first year of life and is no longer present by the beginning of the third year of life. The behavioral pattern is distinct and apparently unrelated to the phenomenon known as separation anxiety. Little is known currently about the etiology of separation anxiety in young children. Current research suggests that there may be a temperamental basis to withdraw from discrepancy or novelty. Such a bias may in some instances lead to the behavioral pattern known as separation anxiety in children.
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