By Tracy G. Cassels
Recently I came across a blog piece by Chaley-Ann Scott claiming that Separation Anxiety Disorder (SAD) was debunked. Now, let me first clarify that I started my degree in a Clinical Psych program, completed my MA in it, before moving to Developmental for my PhD. I have been trained to look at the DSM (the Diagnostic and Statistical Manual of Mental Disorders) critically and to look at treatment options, the efficacy of treatments, and cultural constructs surrounding certain diagnoses. So when I see a piece claiming that a particular diagnosis has been “debunked”, the hairs on my neck stand up and I can’t help but take a very critical eye to it.
This specific piece suffers from the same flaws that many articles touting that certain diagnoses don’t exist suffer from – the very wrong assumption that because something is misdiagnosed or even just overdiagnosed that the entire construct doesn’t exist. And that is wrong. Here I want to talk about a few of the things that are specific to the blog piece in question, but also some issues that come up around diagnoses more generally.
Over- and mis-diagnosing does not negate a construct
This is central to understanding anything to do with mental health. In the aforementioned piece, the authors tries to use examples of 8-month-olds being diagnosed with SAD as an example of how the construct itself is incorrect. But really the issue at hand (and one that the author is actually quite right to bring to the forefront) is that the diagnosis of SAD is completely inappropriate for an 8-month-old and that it is often diagnosed for completely normal behaviour.
The definition of SAD is that children experience anxiety that is beyond what would be expected given a child’s mental and age-appropriate development. Thus an 8-month-old cannot experience SAD. They can experience separation anxiety more generally, but that’s to be expected because that’s part of their wiring. Infants physiologically expect to be stuck to their caregiver for a long period of time in order to ensure their survival, thus no amount of separation anxiety would be inappropriate for their development. So in this sense, the idea of SAD for a baby would be wrong.
But SAD isn’t just diagnosed for infants. SAD is most commonly diagnosed when children experience a severe upheaval – typically a significant move away from a life they know, and more commonly, after the death of a parent. Although we would all imagine that any grief would be appropriate in the latter circumstance, sometimes the manifestation becomes such that a child can’t function. And this is when it becomes a disorder. A child who fears sleeping because he or she might lose another parent, or who cannot go to the bathroom alone for the same reason is a child who is suffering. While it’s nice to say “Just stay with them”, their fears tend to border on irrational and can be similar to someone suffering from Obsessive-Compulsive Disorder for which we know that giving into the fear just feeds it. Not only that, but often times the relief of having the parent close is short-lived; the anxiety and fear that are a part of SAD are pervasive so having a parent close doesn’t always alleviate the symptoms. This last point is key because it really does help differentiate between plain separation anxiety and SAD. A child can experience separation anxiety and be happy with a parent close by, but with SAD, having the parent may only provide temporary relief for the child.
So we can probably all agree that any doctor telling a family that their 8-month-old has SAD is wrong, and in fact that far too many parents are being told their child has a disorder when they don’t, but this doesn’t make the construct invalid, debunked, a myth, or whatever term you’d like to use. It means it’s not well understood by those practicing, or doctors are using a cop-out to appease parents of behaviour that they may find problematic, or there’s even another etiology that is being overlooked in favour of simpler explanations (this last topic is a key point in an article I have in press on ADHD and the potential for faux-ADHD diagnoses Treatment, treatment, treatment Oftentimes, the rebellion against certain constructs stems of the overarching hold the pharmaceutical companies have in our society. People feel that children are put on drugs far too easily (agreed) and it’s more to line the pockets of CEOs than it is to help the children and families. This is a very valid concern that all parents should have and when pharmaceutical recommendations are the first ones given, a long, hard look at your doctor is necessary. Sometimes they will be necessary and helpful, but rarely will a good clinician start you on that path right away unless you’re at risk of harming yourself or others or the symptoms are so severe that it really does seem the best route. In the specific case of SAD, the author of the blog piece recommends you just stay with your child. For normal separation anxiety, I agree, when possible. This brings me to the first treatment point: the treatment has to work for the child and the family. If it doesn’t work for the family, chances are it won’t work for the child either, or could raise all sorts of other problems. Staying home with a child is something I fully support, especially for the first few years of life, but not all families can do this. And to ignore that very real fact when talking about treatment means the treatment you propose is only valid for people with the resources to do that and you have left out those who cannot. I mentioned this in comments on that blog piece earlier (it was posted elsewhere on a site I support – and still do – but has since been removed) and was told that the author knew single parents that homeschooled and so that’s what all families with this situation should do. Personally I think it’s great some single parents can homeschool, but it means these parents have some support for their children for when they have to work. Not all families have that type of support. The recommendations in the original piece for working parents are nice, when doable, and something people and society should strive for as options. But by no means will they work for everyone and to assume that all families can do that is a very privileged position indeed. The second treatment point is this: the treatment has to treat the disorder. As I mentioned above, the idea of just staying home with a child with SAD doesn’t treat the problem because the problem isn’t typical separation anxiety – it’s more than that. From what I could gather, the author of the original piece would propose you simply do what would alleviate the child’s anxiety, no matter how irrational. Go to the bathroom with them, allow them not to sleep if they fear losing you in sleep, etc. Most families (especially if there’s another child in the mix who might also be suffering, though not to the SAD degree from a loss or trauma) can’t function that way. It’s why the behaviour becomes a disorder. And it’s not healthy for the child either. A good clinician will use a variety of gentle techniques to help the child understand and process the loss (if relevant), the anxiety, and help them return to a state in which they can function. There will still be some anxiety, that which is developmentally appropriate, but it won’t cripple them. The one area I found the original piece to be right about was the notion that we have articles and “experts” talking about separating from your child early and often, which is not right. I agree completely with that. And again, this returns to the question of what kind of separation anxiety is normal, something many Western societies have lost sight of (as they have normal sleep behaviours). So while I applaud the notion that we need to start recognizing attachment as a normal and healthy behaviour for infants and children, that should have no bearing on the existence or treatment of SAD. Mental disorders are and aren’t like physical diseases One of the more common criticisms leveled at mental health diagnoses (including ADHD, autism, depression, etc.) is that because they fail to have a known physical etiology, they must somehow be “made up”. There are researchers who believe this (though they are in the minority) and certainly plenty of people with access to the Internet believe this. Let us first start by accepting the idea that there must be a physical etiology for something to be considered a valid disorder or disease (something that is debatable but we’ll accept the premise for now). It has taken us hundreds of years to understand the etiology around the diseases we currently know and accept as real; however, the symptoms and outcomes were always in existence. Simply because we haven’t identified the physical aspect of mental disorders does not mean they do not exist. And in fact, mental disorders are most likely the hardest to identify as the brain is the least understood of all our organs (rightfully so, because if the brain were simple enough to be understood, we wouldn’t be smart enough to understand it). However, this does not mean that people are not doing this very thing. ADHD, for example, has many opponents claiming it is not real, but rather a cultural construct[2]; however, recent reviews of cross-cultural diagnoses and rates[3] suggest that is not the case. Furthermore, a neurobiological explanation has been identified[4] and receives considerable support, bringing ADHD into the realm of the “physical”, like any other disease. However, being neurological, it is incredibly difficult to diagnose with a simple test, and as such behaviours are used as markers, very imperfectly. But almost every mental health disorder is being looked at for a neurobiological explanation, some answers are coming faster than others, but until our understanding of the brain matches our understanding of the body, it will be a slow process. Before we had appropriate physical tests, doctors had to make educated guesses as to what physical ailment a patient had. We are in that same realm with mental health disorders. Our ability to accurately diagnose is limited, but researchers and clinicians strive to fix this and develop a more nuanced understanding of these disorders as well as more accurate ways to diagnose them and treat them. Another problem often cited about mental health disorders is their transient nature. Yes, one can be depressed for a period and then not. SAD is similar, a child can suffer from it but it will go away. Why this is hard for people to understand is beyond me as many physical ailments are the same. Someone gets cancer, seeks treatment, and hopefully it goes into remission. At some point they may even say they’re “cured”. Mental health is no different. Some diseases might require lifelong treatment just as some physical diseases require as much. Others will come and go. And yet more may be one time disorders that are treated, never to return again. All of this is found in physical diseases, so why would we expect mental health to be different? Conclusions SAD and other mental health disorders are real. They are as real as diabetes, heart conditions, and cancer. Are they overdiagnosed? Absolutely. Can they be misdiagnosed? You bet. And should we be concerned about this? Yes. Might our understanding of these disorders change with time? I would be shocked if it didn’t. But ensuring our children and ourselves aren’t misdiagnosed does not mean we throw out the concept of the disorder. It means that when we experience what we perceive to be problems, we first compare the behaviour against what is normative to see how different that behaviour is. In this regard, we need more people to do research on what is normal, as it’s gotten so skewed over the years with the constant changes we have to our society and how we treat families and children. In this view of normative behaviours, we need to make the distinction between what is normal, like separation anxiety or hyperactive activity in a child, versus when a behaviour becomes abnormal, like SAD or ADHD. If you still believe the behaviour is beyond what is normal, and especially if your child or family has undergone something that may be traumatic for your child, you should seek professional help. And like any other doctor, you may need to shop around to find one that can work with your family. It can be a frustrating experience, but the first name in the phone book or the first recommendation may not be for you and it’s important that you trust your instinct in this regard. Then you can focus on treatments that will work for you. Because ignoring a mental health disorder does not help anyone, least of all the person suffering. And no child and no family should have to suffer because of a misguided view that these disorders aren’t real. [1] Cassels TG. ADHD, sleep problems, and bed sharing: future considerations. The American Journal of Family Therapy 2013; 41: 1-13. [2] Anderson JC. Is childhood hyperactivity the product of western culture? Lancet 1996; 348: 73-74. [3] Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA. The worldwide prevalence of ADHD: a systematic review and metaregression analysis. American Journal of Psychiatry 2007; 164: 942-948. [4] Ali O. Childhood hyperactivity. Lancet 1996; 348: 895-896.
As someone who takes psychology, psychiratry (sp?), and especially anything in the DSM with not only a grain of salt but the whole salt lick, I think the objection (for many) isn’t that such things ‘don’t exist’ but rather that they are pathological or ‘disorders’ only when they are allowed (or inversely disallowed in some instances). 100 years ago, 500 years ago, in most instances 60 years ago someone with ‘ADHD’ was called ‘energetic’, ‘fidgety’, or said to have a short attention span. Maybe they got a few more spankings, switchings, etc than an ‘average’ child, but ultimately they were perfectly normal and a job they were perfectly capable of doing would have been found. Sure, ADHD (when it’s not woefully overdiagnoised) exists, but it exists only as a pathological condition because we’ve determined merely unusual behavior must be a disorder to be diagnosed, treated, medicated, and, if possible ‘cured’. Likewise 100, 500, etc years ago OCD didn’t exist, no one would have let it. We’ve talked on this before. OCD exists when it’s fostered and carefully tended, the treatment to ‘cure’ it is to *not* encourage the behavior and to enforce normal behavior. 100 years ago a teen starts obsessively washing their hands they would have been dragged away from the sink by an ear, told they were being ridiculous, and sent to their work. A family wouldn’t agree abide by the insanity that is today foisted upon them by OCD sufferers, they would have nipped such behavior in the bud the first time it happened by refusing to participate or let their family member participate. Likewise with this SAD above, until the advent of modern psychology a child who said they were too afraid to go to the bathroom by themselves would have been given a chuckle and a kiss and sent firmly to the bathroom, and if it continued would have been sent there with a swat if necessary. Clinging to mom or dad obsessively simply wouldn’t be an option, mom or dad has things to do. The behavior simply wouldn’t have been allowed to escalate to ‘pathological’, the ‘treatment’ now given by trained professionals for hundreds of dollars would have been administered by the family from the start. So very much of the DSM is focused on creating a disorder where none has ever existed and none needs exist purely so ‘professionals’ can come along and cure it that it’s extremely hard to take them seriously even on the rare instance that they are being serious. If oncologists first gave their patients cancer before they charged for treating it I guarentee people would stop taking cancer seriously as well.
I’m not saying that’s the opinion of the above mentioned, your report that he suggests treating seperation anxiety by going along with it is, if nothing else, rather more likely to turn normal, transient behavior into a pathological disorder, is in fact the professional-induced type of behavior that lead to so many of these problems to begin with. Rather a brief example why I and those like me would say SAD ‘doesn’t exist’, or, more precisely, does not deserve a lable as a ‘disease’ or ‘disorder’ or anything that needs medication, professionals, or diagnosis. It’s at worst a mismanagement, a mismanagement encouraged by professionals who have spend the last 80-100 years convincing the lay-public that only professionals are capable of dealing with life’s idiocyncracies, of what is a perfectly normal and transient display of childhood insecurities.
That all being said I do think your point that merely over diagnosing or misdiagnosis does not mean something doesn’t exist and merely ignoring behavior isn’t going to get anyone anywhere.
I see your point, but I think that the diagnoses being real doesn’t preclude family being able to offer the best treatment early and before behaviours become pathological. However, both of us would agree that parenting today is generally very different than in the past and as such sometimes other options are needed. In this case, therapy from someone who is trained (and if good is doing what families may have done years ago).
Jespren,
I certainly see where you’re coming from, but you seem to put an overemphasis on the corrective behaviors (ie: disciplinary measures and/or punishments) employed by previous generations, and lack emphasis on the VAST differences in diet, pastimes, school and work environments, and societal expectations between those generations and our current culture. First, the diet debate: while there is much debate over the extent to which diet is the cause of various psychological disorders and mental/intellectual disabilities in our current society, there is no denying the drastic changes over the last several decades, most notably a drastic increase in packaged and processed foods. I personally would be shocked if there wasn’t some level of causation to accompany the correlation between these changes in diet and increase in recognized brain dysfunctions. Exercise has also been in drastic decline, which has been shown to have innumerable negative effects on every aspect of a person’s being: intellectual, emotional, and physical. Finally, the expectations in our society are frankly ridiculous and narrow-minded. They are designed for an invented “majority” who fit a very particular mold which we vaguely describe as being “normal”. We expect children to sit for developmentally inappropriate lengths of time in a classroom environment with little to no exercise or social interaction. Children are separated by age group, and banned from environments in which they might actually witness, experience, and learn from the behaviors and expectations that they will be required to abide by in their future school and work settings. If a child is “smart”, it is generally expected that he/she will excel in every subject, and if they are deemed “special needs” it is more often than not assumed that they are intellectually inferior and not granted access to opportunities to excel in their strengths. Upon broaching adulthood, they are pushed to attend college, whether or not they have the skills, drive, and study habits to succeed. Cue college dropouts who now have to choose between “entry level” jobs that don’t even pay enough for housing, or the lesser known trade school route available for jobs that might pay only slightly more than the aforementioned entry level positions. If one ends up in one of these positions, there is a societal tone of inferiority to cope with, in addition to the fiscal difficulties. In the past, not only did most children have access to one or more close adults for guidance, discipline, and instruction for more hours in the day, a child who was unable to focus well enough to thrive in the classical classroom, or got the switch more than his/her fair share, would likely have been pulled from school to assist at home with younger siblings, farming chores, street jobs (newsies, etc.), or trade apprenticeship, where their “wayward” behaviors would be less obvious or even utilized. Or, in a worst-case scenario and as was the case with far too many innocent children, sent away by prideful, embarrassed parents, to be institutionalized, orphaned, or even go “missing”. People with mental and intellectual disabilities who managed to make it to adulthood could most likely be accounted for in the numbers of drunkards, recluses, bums, “eccentrics”, etc.
In summary:
1) To assume that these disorders didn’t exist prior to our “creating” them, is to blatantly choose to ignore the existence of asylums, institutions, and various other ways that society previously sought to hide these suffering individuals from view, as well as to completely disregard the extensive work that has been done by many incredibly intelligent and learned people to try to understand why those same people struggle with the very things that come so naturally to most others.
2) To suggest that all of these “created” disorders should simply be prevented by a certain type of parenting fails to take into account not only the various dietary and environmental influences, but also the fact that most children these days are essentially being raised by teachers and or childcare providers who are responsible for 20+ children from vastly different backgrounds of which the caregivers are only granted the brief glimpses provided by their brief interactions with each child, and in order to provide well for said children, most households feel pressured to have both parents working outside the home. Not to mention the societal expectations of extracurricular activities which further limit the potential for parent-child interactions.
I agree that the *increase* in the prevalence of many psychological and intellectual disorders is at least in part a result of changes in parenting and expectations, but I feel that to dismiss the entire category “with the whole salt-lick” requires a level of ignorance of or disregard for a vast amount of historical information that quite simply devalues a substantial population of individuals who work harder than you can begin to imagine just to pull off the impression of being as functional as the societal “norm” requires.
To be frank, I’m one of those people, and my parents’ metaphorically “pulling me away from the sink” did little to prepare me for the challenges I’ve faced, but thanks for sharing your dismissive view on the few things that have actually helped me adapt, function, and live to see another few years.
To the OP: thank you for a well worded, informed and informative article. I look forward to reading your take on ADHD.
I agree. Misdiagnosis is a big issue. As a clinical therapist myself, and the Vice President of clinical operations for a mental health organization, I have seen and treated children and adults for separation anxiety issues, and the obsessive compulsive traits that you references (though in practice they don’t look quite that similar). Separation anxiety issues are severely traumatic for many children and can actually create a trauma response such as PTSD in a child who is already highly sensitized due to higher levels of cortisol (or even things like undiagnosed food allergies as the can stress the autonomic nervous system). In my experience, the trauma response is the one under diagnosed because separation is seen as a mundane occurrence despite the evolutionary drive to the contrary. As a society we don’t seem to accept that trauma can be triggered by a separation itself. So some kids come in with clear trauma responses, (which a physician has generally called separation anxiety). This is a big problem, because treatment for an anxiety disorder, a simple separation transition issue or full on trauma is very different. Separation anxiety is a normal part of experience, because of how we are wired neurologically. It is very hard to see this pathlogized while at the same time see children with trauma responses because parents are told they just have to leave them in a certain way. It’s tricky due to the divide between biology and current environmental functioning. (For the record I spent the first half of the article equating SAD with seasonal affective disorder because the acronym is more commonly used for that in therapy circles. I was like “Kids with SAD! Get them outside!” LOL)
In response to the first comment, obsessive compulsive drives have always existed, but we were less exposed to them, or the behaviors were allowed to be purged in more adaptive ways. The environmental and hormonal imbalances that can trigger such behaviors are far more prevalent. Some can be linked to early attachment issues, which in our ancestral lineage would not have been an issue, primarily because a child alone (or with fractured attachment) was a dead child. You can’t grow up to manifest disorder that way. It’s a great way to keep it out of the population I suppose. Now, the things needed to correct such issues on an underlying level strike mothers as optional, because our children would survive even without our higher levels of investment, and we are no doubt made to be flexible. But the obsessive compulsive traits and anxiety responses are not cured when someone is pulled away from a sink for washing their hands too much. That person was trying to find a way to calm a heightened autonomic/sympathetic response that they were unable to do so because of possibly because of earlier regulation issues. It’s a reason for people to cut, to become bulimic, to screw with light switches. They need a way to regulate. Yanking them from it can trigger internalization, so they may not show the behavior but they suffer more internally and learnt hat they can’t show it to others. Then later when they are under their own control, behaviors tend to be much much worse, and done in private. Some start with the light switches and go on to remove their own eye (true story). It’s very real, and not a matter of yanking someone from a hand washing station. .
…and yeah, as Traci said, these people don’t need me most of the time if early attachment processes and childhood emotional regulation is supported correctly. Early separation anxiety is normal and expected. We have to watch the way it’s done and the personality and early processes of individual children though to avoid traumatic response
Interesting discussion. For further elucidation on separation anxiety “disorder” I would highly recommend Dr. Gordon Neufeld’s material, particularly on anxiety (there is a 4 hour dvd but other youtube to get a taste). As a clinical practitioner I particularly find his concepts of intensified pursuit, the process around adaptation, how it is all related to attention and tuning out/defenses, and how to bring a child to true rest by restoring right hierarchies (becoming an alpha) and that the provision must be greater than the pursuit for a child to find this rest. Now that I have an in-depth knowledge of his paradigm I see all these underlying instinctual dynamics everywhere, and can’t believe I didn’t see it before. The one response I get from parents I work with was “Oh my goodness, how did I not see this, I just wish I knew this years ago”.