What is separation anxiety disorder?
Separation anxiety disorder is the excessive fear or anxiety concerning separation from home or attachment figures, which is inappropriate for the person’s developmental level. Attachment figures are usually parents, but may also be siblings, grandparents, or other caregivers or, for adults, children or spouses. The DSM-5 criteria no longer include an age-at-onset restriction because many adults report onsets after age 18 years. Symptoms in children need only persist for 4 weeks to meet criteria, but persist longer than 6 months with adult-onset separation anxiety disorder.
The worldwide lifetime prevalence of separation anxiety disorder is 4.8 percent, with 43 percent of these patients experiencing onset after age 18 years. It is the most common anxiety disorder in children under the age of 12. The lifetime prevalence is more common in women than in men, though it is the same when considering only the adult-onset type. More than half of the patients go into remission within the first 10 years after onset. Over the course of the lifetime, separation anxiety disorder is associated with a broad range of comorbid mood and anxiety disorders, including Major Depressive Disorder, Bipolar Disorder, Panic Disorder, Social Anxiety Disorder, and Specific Phobia.
Symptoms of Separation Anxiety Disorder (Sadock, et al., 2017)
In separation anxiety disorder there is excessive and developmentally inappropriate fear of being away from an attachment figure, and avoidance of such separations due to irrational beliefs about the consequences of such separations. They may refuse to leave home because of the fear of permanent separation from an attachment figure. They may demonstrate sadness, withdrawal, and aggression.
They worry about the possibility of any harm that might befall their loved ones (e.g., parent getting into a car accident, spouse becoming ill or dying) or oneself (e.g., getting lost, being kidnapped, having an accident) upon separation. This worry leads to the avoidance of activities apart from the presence of the attached figure. Patients can fear sleep, and when they do manage to sleep, they often have nightmares regarding separation. Finally, excessive worry can be associated with physical symptoms of anxiety.
Symptoms may include avoidant behaviors such as refusal to go to school or work, sleep alone, or be without the attachment figure. Other common symptoms include physical symptoms such as stomachaches or nausea and cardiovascular symptoms (e.g., pounding heartbeat, lightheadedness).
At home, children display clingy behavior and follow their caregiver. They do not like to be alone in any room and do not want to sleep alone. Also, they are not comfortable with babysitters and may try to call parents frequently. They may throw tantrums or become panicky or oppositional when anticipating separation.
At school, the child may want to call their parents frequently to check-in or visit school nurse frequently to complain of physical ailments. They may become restless and fidgety when they are anxious. They may be unable to attend to classroom work. Separation anxiety can also result in school refusal, showing up as being late to school or frequent absences, leading to academic and social impairment.
In public, children with separation anxiety stay close to their caregiver. They do not like to attend birthday parties, sleepovers, camps, and extracurricular activities if the attachment figure is not present.
To summarize, the symptoms can be:
- Excessive distress about being separated from attachment figure
- Unrealistic and excessive worry that the parent or caregiver will be harmed (e.g., illness or accident) if they leave them alone
- Unrealistic and excessive worry that he or she will be harmed (e.g., getting lost, being kidnapped, having an accident) if he or she leaves the attachment figure
- Refusal to go to school in order to stay with the attachment figure
- Heightened fear of being alone
- Being very clingy, even when at home
- Needing to know where the attachment figure is at all times
- Refusal to go to sleep without the attachment figure being nearby or to sleep away from home
- Repeated nightmares about being separated
- Complaints of physical symptoms, such as headaches, stomachaches, nausea, and lightheadedness when they know they will be separated from attachment figure, such as on school days
- Panic or temper tantrums at times of separation from parents or caregivers
Some older children and adolescents with separation anxiety may not present obvious impairment or distress, as their parents and school find ways to accommodate the child’s fears to decrease their distress.
Diagnosis of Separation Anxiety Disorder
The diagnostic criteria of separation anxiety disorder as per DSM-5 are as follows (American Psychiatric Association, 2013):
- Excessive fear or anxiety about separation from attachment figures, which is developmentally inappropriate, with at least three of the following:
- Distress about separation from home or attachment figures.
- Worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death.
- Worry about an untoward event happening to oneself (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from attachment figure.
- Refusing or not liking to go out, away from home, to school, to work, or elsewhere because of fear of separation.
- Not wanting to be alone or without major attachment figures at home or in other settings.
- Not wanting to sleep away from home or at home alone in their bedroom.
- Repeated nightmares involving the theme of separation.
- Complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from attachment figures occurs or is anticipated.
- The above symptoms should last at least 4 weeks in children and adolescents and typically 6 months or more in adults.
- There should be clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.
- The disturbance is not better explained by another mental disorder, such as autism spectrum disorder, psychotic disorders, agoraphobia, generalized anxiety disorder, or illness anxiety disorder.
Causes of Separation Anxiety Disorder
Developmental factors. Toddlers with a “behaviorally inhibited” temperament are at greater risk for developing clinical anxiety disorders in childhood.
Genetic factors. Children of parents with an anxiety disorder are up to five times more likely to be diagnosed with an anxiety disorder. There is also an increased risk if a parent has panic disorder or major depression.
Environmental factors. Children can learn anxious and fearful responding from their environment in three ways: direct negative experience, a false alarm (perceiving a situation negatively, without direct evidence supporting this belief); and vicariously (witnessing or being told something is dangerous).
Parenting style. Anxiety-enhancing parenting approaches, such as parental intrusiveness, overprotection, and psychologically controlling behavior in the child’s daily activities may also contribute to a child’s risk for developing anxiety. Such parenting approaches do this by promoting dependency and reducing the development of autonomy, which prevents the child from having a range of experiences that foster broad and complex coping skills.
Course and Prognosis
The course of separation anxiety disorder is not the same for all children. Some children spontaneously remit; some remain anxious but do not avoid separation triggers, and some truly evolve into other anxiety disorders or depression. They are at an increased risk of developing subsequent panic disorder with agoraphobia, specific phobia, generalized anxiety disorder, OCD, pain disorder, and alcohol dependence.
Treatment (Sadock, et al., 2017) (Tasman, et al., 2015)
Immediate treatment goals include reduction of symptoms, behavioral avoidance, and interpersonal and academic dysfunction while minimizing side effects. Cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitor (SSRI) antidepressant medications are effective. Immediately following treatment with CBT or an SSRI, over 60% of anxious youth show clinically significant improvement.
CBT has the greatest empirical support and is considered the treatment of choice. Manualized CBT programs for child anxiety such as Coping Cat, Coping Koala, SET-C, and FRIENDS, generally consist of 10 to 16 1-hour sessions delivered in child-focused individual, family, or group formats. CBT includes the following five components:
- Psychoeducation: Providing education about anxiety and its symptoms. Psychoeducation for CBT generally begins with a review of the relationship between thoughts (e.g., “I will fail the test”), feelings and physiological sensations (e.g., anxiety; sweating, muscle tension), and behavior (e.g., avoidance of school). Children are taught about how anxiety can be useful in some situations (e.g., being wary of taking a ride with a stranger) but may serve as a “false alarm” in other situations (e.g., having a panic attack before giving a report in class). Children are asked to record their anxious thoughts, feelings, and behaviors between sessions. The rationale for exposure therapy is discussed, such that avoidance of feared situations increases anxiety over time due to the prevented acquisition of new information confirming the actual success or safety of the feared situation.
- Relaxation skills: Including progressive muscle relaxation, relaxation breathing, and guided imagery.
- Cognitive restructuring: Allows children to learn how to catch the negative automatic thoughts that they have in anxiety-provoking situations (e.g., “I might trip and embarrass myself in front of everyone”) and look for evidence to challenge the thoughts (e.g., “I tripped that one time in the cafeteria, but that was when the floor was really slippery from the rain”) and to assess more accurately the consequences of an event (e.g., “If I do trip, people might laugh at first but they’ll probably forget about it pretty soon”). Older children are taught the names of a variety of cognitive distortions that help them categorize their typical automatic thoughts (e.g., mind reading, “he must think I’m stupid,” or catastrophizing, “If I trip in the cafeteria I’ll never have any friends!”).
- Exposure techniques: Graduated, systematic, and controlled exposure to feared situations and stimuli. By beginning with relatively low-level triggers, anxious youth can habituate to these situations and develop a sense of mastery as they learn that they can successfully face their anxiety.
- Relapse prevention: Aims to consolidate gains made in treatment, review skills, and provide children with the ability to notice and intervene when warning signs of relapse are present. During this part of treatment, children learn to look out for opportunities to engage in exposures and practice the skills they have learned in their daily life.
Throughout CBT treatment, children are encouraged to engage in between-session practice in order to learn to generalize their learning. Also in use are computer-assisted treatments such as BRAVE-ONLINE and Camp-Cope-A-Lot, which combine computer-based sessions with online and phone contact with a CBT clinician. Computer-assisted and in-person CBT produce statistically similar clinical improvements.
A new computer-based treatment for child anxiety disorders is Attention Bias Modification (ABM; also called Cognitive Bias Modification). ABM modifies the biases toward threat in anxious individuals.
SSRIs are considered first-line medications, though no SSRIs are approved by the US Food and Drug Administration (FDA) for use in children and adolescents with anxiety. They include fluvoxamine (Luvox), fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), duloxetine (Cymbalta), and the tricyclic antidepressant imipramine up to 200 mg daily (Tofranil).
Treatment for 6 to 12 months after remission in symptoms before attempting a slow, controlled taper may provide extended benefit and may prevent a relapse after medication discontinuation. However, longer-term treatment may be necessary if children experience a return of symptoms when medication doses are missed or during known trigger points such as the start of school (separation anxiety), grade reports or final examinations (generalized anxiety), or group activities at school or camp (social).
Benzodiazepines may be considered for short-term augmentation of antidepressants early in the course of treatment for some highly anxious children.
American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Publishing.
Sadock, B. J., Sadock, V. A. & Ruiz, P., 2017. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry. 10th ed. Philadelphia: Wolters Kluwer.
Tasman, A. et al. eds., 2015. Psychiatry. 4th ed. Oxford: Wiley Blackwell.