accident, becoming ill) that causes separation from a major attachment figure persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure repeated nightmares involving the theme of separation repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated classification separation anxiety is common for infants between the ages of eight and fourteen months and occurs as infants begin to understand their own selfhood—or understand that they are separate persons from their primary caregiver. infants oftentimes look for their caregivers to give them a sense of comfort and familiarity, which causes separation to become challenging. subsequently, the concept of object permanence emerges—which is when children learn that something still exists when it cannot be seen or heard, thus increasing their awareness of being separated from their caregiver. consequently, during the developmental period where an infant's sense self, incorporating object permanence as well, the child also begins to understand that they can in fact be separated from their primary caregiver. they see this separation as something final though, and don't yet understand that their caregiver will return causing fear and distress for the infant. it is when an individual (infant, child, or otherwise) consistently reacts to separation with excessive anxiety and distress and experiences a great deal of interference from their anxiety that a diagnosis of separation anxiety disorder (sad) can be warranted. one of the difficulties in the identification of separation anxiety disorder in children is that it is highly comorbid with other behavioral disorders, especially generalized anxiety disorder. behaviors such as refusal or hesitancy in attending school or homesickness for example, can easily reflect similar symptoms and behavioral patterns that are commonly associated with sad, but could be an overlap of symptoms. the prevalence of co-occurring disorders in adults with separation anxiety disorder is common and includes a much broader spectrum of diagnostic possibilities. common co-morbidities can include specific phobias, ptsd, panic disorder, obsessive-compulsive disorder, and personality disorders. it is very common for psychological disorders to overlap and even lead to the manifestation of another, especially when it comes to anxiety disorders. because of the variation and overlap in symptoms a proper, thorough evaluation of the individual is critical to distinguish the differences and significance. an important signifier to establish a difference between sad and other anxiety or psychological disorders is to investigate where the individual's fear of separation is stemming from; this can be accomplished by asking "what they fear will occur during a separation from their significant other". what stands out about sad, as mentioned above, are the avoidance behaviors which present within an individual. individuals "typically exhibit excessive distress manifested by crying, repeated complaints of physical symptoms (e.g., stomach aches, headaches, etc.), avoidance (e.g., refusing to go to school, to sleep alone, to be left alone in the home, to engage in social events, to go to work, etc.), and engagement in safety behaviors (e.g., frequent calls to or from significant others, or primary caregivers)". assessment methods assessment methods include diagnostic interviews, self-report measures from both the parent and child, observation of parent-child interaction, and specialized assessment for preschool-aged children. various facets of a child's development including social life, feeding and sleep schedules, medical issues, traumatic events experienced, family history of mental or anxiety health issues are explored. the compilation of aspects of a child's life aids in capturing a multi-dimensional view of the child's life. additionally, while much research has been done in efforts to further understand separation anxiety in regards to the relationship between infants' and their caregivers, it was behavioral psychologist, mary ainsworth, who devised a behavioral evaluation method, the strange situation (1969), which, at the time, was considered to be the most valuable and famous body of research in the study of separation anxiety. the strange situation process assisted in evaluating and measuring the individual attachment styles of infants between the ages of 9 and 18 months. in this observational study an environment is created that fluctuates between familiar and unfamiliar situations that would be experienced in everyday life. the variations in stressfulness and the child's responses are observed and, based on the interaction behavior that is directed towards the caregiver, the infant is categorized into one of four different types of attachment styles: 1. secure, 2. anxious-avoidant, insecure, 3. anxious-ambivalent/resistant, insecure and 4. disorganized/disoriented. clinicians may utilize interviews as an assessment tool to gauge the symptomatic occurrences to aid in diagnosing sad. interviews may be conducted with the child and also with the attachment figure. interviewing both child and parent separately allows for the clinician to compile different points of view and information. commonly used interviews include: anxiety disorders interview schedule for the dsm-iv, child parent versions (adis-iv-c/p) diagnostic interview schedule for children, version iv (disc-iv) schedule for affective disorders and schizophrenia for school-aged children-present and lifetime version iv (k-sads-iv) self-report measures this form of assessment should not be the sole basis of a sad diagnosis. it is also important to verify that the child who is reporting on their experiences has the cognitive and communication skills appropriate to accurately comprehend and respond to these measurements. an example of a self-report tool that has been tested is: the separation anxiety assessment scale for children (saas-c). the scale contains 34 items and is divided into six dimensions. the dimensions in order are: abandonment, fear of being alone, fear of physical illness, worry about calamitous events, frequency of calamitous events, and safety signal index. the first five dimensions have a total of five items while the last one contains nine items. the scale goes beyond assessing symptoms; it focuses on individual cases and treatment planning. observation as noted by altman, mcgoey & sommer, it is important to observe the child, "in multiple contexts, on numerous occasions, and in their everyday environments (home, daycare, preschool)". it is beneficial to view parent and child interactions and behaviors that may contribute to sad. dyadic parent-child interaction coding system and recently the dyadic parent-child interaction coding system ii (dpics ii) are methods used when observing parents and children interactions. separation anxiety daily diaries (sadd) have also been used to "assess anxious behaviors along with their antecedents and consequences and may be particularly suited to sad given its specific focus on parent–child separation" (silverman & ollendick, 2005). the diaries are carefully evaluated for validity. preschool-aged children at the preschool-aged stage, early identification and intervention is crucial. the communication abilities of young children are taken into consideration when creating age-appropriate assessments. a commonly used assessment tool for preschool-aged children (ages 2–5) is the preschool age psychiatric assessment (papa). additional questionnaires and rating scales that are used to assess the younger population include the achenbach scales, the fear survey schedule for infants and preschoolers, and the infant–preschool scale for inhibited behaviors. preschool children are also interviewed. two interviews that are sometimes conducted are attachment doll-play and emotional knowledge. in both of the assessments the interviewer depicts a scenario where separation and reunion occur; the child is then told to point at one of the four facial expressions presented. these facial expressions show emotions such as anger or sadness. the results are then analyzed. behavioral observations are also utilized when assessing the younger population. observations enable the clinician to view some of the behaviors and emotions in specific contexts. treatment non-medication based non-medication based treatments are the first choice when treating individuals diagnosed with separation anxiety disorder. counseling tends to be the best replacement for drug treatments. there are two different non-medication approaches to treat separation anxiety. the first is a psychoeducational intervention, often used in conjunction with other therapeutic treatments. this specifically involves educating the individual and their family so that they are knowledgeable about the disorder, as well as parent counseling and guiding teachers on how to help the child. the second is a psychotherapeutic intervention when prior attempts are not effective. psychotherapeutic interventions are more structured and include behavioral, cognitive-behavioral, contingency, psychodynamic psychotherapy, and family therapy. anchors away program for children with anxiety disorder. exposure and behavioral therapy behavioral therapies are types of non-medication based treatment which are mainly exposure-based techniques. these include techniques such as systematic desensitization, emotive imagery, participant modelling and contingency management. behavioral therapies carefully expose individuals by small increments to slowly reduce their anxiety over time and mainly focuses on their behavior. exposure based therapy works under the principle of habituation that is derived from learning theory. the core concept of exposure therapy is that anxiety about situations, people, and things does not go away when people avoid the things that they fear, but rather, the uncomfortable feelings are simply kept at bay. in order to effectively diminish the negative feelings associated with the situation of fear, one must address them directly. in order to administer this treatment, the therapist and the anxious child might sit together and identify progressively intense situations. as each situation is dealt with masterfully, the child advances to the next phase of intensity. this pattern continues until the child is able to handle being away from their parent in a developmentally typical way that causes them and their caregiver(s) minimal amounts of stress. while there is some controversy about using exposure therapy with children, it is generally agreed upon that exposure therapy in the context of sad is acceptable as it may be the most effective form of therapy in treating this disorder and there is minimal risk associated with the intervention in this context. contingency management contingency management is a form of treatment found to be effective for younger children with sad. contingency management revolves around a reward system with verbal or tangible reinforcement requiring parental involvement. a contingency contract is written up between the parent and the child, which entails a written agreement about specific goals that the child will try to achieve and the specific reward the parent will provide once the task is accomplished. when the child undergoing contingency management shows signs of independence or achieves their treatment goals, they are praised or given their reward. this facilitates a new positive experience with what used to be filled with fear and anxiety. children in preschool who show symptoms of sad do not have the communicative ability to express their emotions or the self-control ability to cope with their separation anxiety on their own, so parental involvement is crucial in younger cases of sad. cognitive behavioral therapy cognitive behavioral therapy (cbt) focuses on helping children with sad reduce feelings of anxiety through practices of exposure to anxiety-inducing situations and active metacognition to reduce anxious thoughts. cbt has three phases: education, application and relapse prevention. in the education phase, the individual is informed on the different effects anxiety can have physically and more importantly mentally. by understanding and being able to recognize their reactions, it will help to manage and eventually reduce their overall response. according to kendall and colleagues, there are four components which must be taught to a child undergoing cbt: recognizing anxious feelings and behaviors discussing situations that provoke anxious behaviors developing a coping plan with appropriate reactions to situations evaluating effectiveness of the coping plan in the application phase, individuals can take what they know and apply it in real time situations for helpful exposure. the most important aspect of this phase is for the individuals to ultimately manage themselves throughout the process. in the relapse prevention phase, the individual is informed that continued exposure and application of what worked for them is the key to continual progress. a study investigated the content of thoughts in anxious children who suffered from separation anxiety as well as from social phobia or generalized anxiety. the results suggested that cognitive therapy for children suffering from separation anxiety (along with social phobia and generalized anxiety) should be aimed at identifying negative cognition of one's own behavior in the threat of anxiety-evoking situations and to modify these thoughts to promote self-esteem and ability to properly cope with the given situation. cognitive procedures are a