08242017Headline:

Separation Anxiety Disorder: Not ‘Debunked’ and Very Much Real

Recently I came across .  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[1]).

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.

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