People with Separation Anxiety Disorder experience an excess amount of anxiety or fear when separated, or anticipate separating, from major attachment figures, (e.g., parents, spouse, children, etc.). Their overwhelming level of anxiety is not developmentally appropriate, is persistent, and can cause significant distress sometimes impairing social, school or work functioning.
Separation Anxiety Disorder is one of the most common and one of the earliest onset anxiety disorders in children. While separation anxiety disorder tends to begin in childhood, adolescent or adult onset can also occur. Approximately 4.8% of people will experience separation anxiety disorder in their lifetime.2 Separation anxiety disorder is best treated by cognitive behavioral therapy. Medication is sometimes prescribed to alleviate anxiety and make therapy more effective.1
Signs of Separation Anxiety Disorder
The fear of permanently never being reunited again with an attachment figure is at the core of separation anxiety disorder. People with separation anxiety disorder excessively worry about harm befalling their attachment figure or themselves.
Signs of Separation Anxiety Disorder in Children
Separation Anxiety Disorder often manifests differently at different ages. For example, younger children might not vocalize any specific worries and may only show upset when separation is experienced.
While they might not be talking about their concerns, children with separation anxiety disorder often exhibit behavioral signs of the disorder, such as:
- Shadowing a parent around the house vs. playing alone in their room
- Acting clingy at social functions or in public
- Refusing to go to school or finding excuses why they should stay home
- Experiencing physical symptoms like headaches, stomachaches or vomiting associated with separating
- Feeling scared to sleep alone
- Having nightmares about separation
- Begging attachment figure not to leave, screaming, crying or even becoming aggressive when forced to separate1
As children age, anticipatory worries about being permanently separated from their attachment figures tend to emerge. Anxiety about specific dangers that might cause that separation to occur (e.g. kidnapping, car accidents, illness/death, parents never returning) are common.1
Signs of Separation Anxiety Disorder in Teens
Adolescents might deny anxiety about separation and keep their fearful thoughts to themselves. Anticipatory or actual separation might trigger an anxiety reaction resulting in heart palpitations or feeling faint.
Some indicators of potential separation anxiety disorder in older children and teens include:
- Disliking, refusing to attend, or not wanting to stay the full day at school
- Not wanting to join extracurricular activities
- Insisting on knowing where parents are at all times
- Feeling uneasy when parents are not home
- Reluctance to engage in independent activities (going to a store, traveling, sleeping at a friend’s house, etc.).
Teens with separation anxiety disorder might choose to attend a local college rather than separate from the nuclear family.3
Signs of Separation Anxiety Disorder in Adults
Adults with Separation Anxiety Disorder tend to experience more of the cognitive or emotional upset of the disorder vs. the somatic complaints common with children. Adults might have anxiety regarding their parents, but for most, the attachment figures tend to be intimate partners and children.
Adults with separation anxiety disorder might exhibit or experience the following:4
- Frequently checking on the whereabouts and safety of their partner and/or children to the point it interferes with work and social functioning
- Marked distress when separating (including separations due to life transitions such as getting married or moving)
- Physical symptoms (heart palpitations, dizziness, feeling faint) when separated
- Recurring nightmares with content expressing the person’s fear of separation (unfaithful spouse, family destroyed by fire, murder, etc.)
Normal Separation Anxiety in Young Children vs Separation Anxiety Disorder
Separation Anxiety and Separation Anxiety Disorder are differentiated by the intensity and persistence of symptoms. Separation anxiety might elevate to separation anxiety disorder when a child’s distress and resultant behaviors are intense and out of proportion to reality. It’s when anxiety is prolonged (4 weeks or more) and so severe it interferes with daily functioning that a diagnosis of separation anxiety disorder is considered.
Separation anxiety is a typical developmental phase that most babies and toddlers experience. Usually it begins between 6 and 8 months old, peaks at 15-18 months, and slowly diminishes between two and four years old. Separation anxiety plays an adaptive role in that it keeps very young children nearby and safe. Coupled with stranger anxiety, it contributes to the process of an infant learning to differentiate their social environment.5
First day of preschool or kindergarten jitters are common. Children crying and clinging upon separation is expected, and with reassurance, most students calm down. Children with separation anxiety disorder, however, may never fully acclimate. They remain fearful, worried their parents may never return. Children with separation anxiety disorder may be tearful, unable to eat or to fully concentrate on academics or play. Nighttime anxiety about tomorrow’s impending separation may disrupt sleep. Their distress significantly impedes their functioning.
Symptoms of Separation Anxiety Disorder
Separation Anxiety Disorder can be expressed in a variety of ways and not all people with separation anxiety disorder will exhibit all symptoms. It is important to note that simply evidencing some of these indicators is not enough to be diagnosed with separation anxiety disorder.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), lists the symptoms of separation anxiety disorder as:1
- Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures
- Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness injury, disasters or death
- Persistent and excessive worry about experiencing an untoward event, (getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure
- Persistent reluctance or refusal to go away from home to school, 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 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
Causes of Separation Anxiety Disorder
No single factor determines the development of separation anxiety disorder. Most complex behaviors (like anxiety disorders), are believed to be created by an interplay of a person’s genetics and environment. While a person might be genetically predisposed to develop certain traits or disorders, the environment (experiences a person has), might determine whether or not those traits or disorders ever emerge.6
Biological, environmental, and physiological factors are all believed to contribute to the development of Separation Anxiety Disorder. If a parent or other blood relative has an anxiety disorder, you might be at risk for one too. Environmental factors, such as a traumatic loss (death, divorce, move) or learned anxiety reactions from caregivers can trigger separation anxiety disorder.
There is some evidence that children with separation anxiety disorder have a greater sensitivity to carbon dioxide. This same sensitivity has been linked to adults with Panic Disorder, which might suggest a link between the two conditions.7 An individual’s brain chemistry is suspected to play a role in separation anxiety disorder as are cognitive biases, including attentional bias to emotional (especially threatening) stimuli.
Some common causes and triggers of separation anxiety include:
- Insecure Attachment: This is the emotional connection formed between an infant and their primary caretaker. While a secure attachment ensures your child feels secure and calm enough for optimal development, an insecure attachment (one that is contaminated by mistrust or fear) can factor into childhood problems such as separation anxiety.10
- Family Factors: Children watch and learn from their caregivers. If a parent tends to have anxious reactions, there is more of a chance their children will develop the same.
- Genetics: Studies have shown that anxiety, in general, is an inheritable trait. Having a blood relative with any anxiety disorder might predispose a person to developing one themselves.
- Life Stressors and Transitions: Events that force separation, (divorce, death of a family member or pet, moving, marriage, going to college, etc.), can trigger separation anxiety disorder.
- Childhood traits of shyness or inhibition11
- Serotonin and Dopamine Levels: These are two neurotransmitters (chemical messengers in the brain) which have been linked to emotions. When not at optimal levels, people can feel anxious.12
How Is Separation Anxiety Disorder Diagnosed?
Licensed mental health professionals can diagnose separation anxiety disorder. To qualify for the diagnosis, 3 of the 8 separation related criteria outlined in the DSM-5 must be met. The separation anxiety must cause impairment in social, occupational, or academic functioning. The symptoms must persist for 4 weeks or more in children and 6 months or more for adults, and the disturbance must not be better explained by another disorder such as Generalized Anxiety Disorder, Social Anxiety Disorder, etc.1
For persistent physical symptoms, a medical exam to rule out health issues will be requested. Typically, clients and/or parents will undergo a structured interview to assess patterns of behavior surrounding the separation anxiety. The clinician will consider the developmental stage of the patient, the patient’s culture, the acute and chronic stressors they are facing, how long the anxiety has been present and potential commonalities with other possible disorders.
Disorder-specific rating scales, such as The Severity Measure for Separation Anxiety Disorder (for adults) and The Separation Anxiety Assessment Scale of Children, offer simple, quick ways to screen for potential separation anxiety disorder and to monitor treatment progress.10
Treatment of Separation Anxiety Disorder
The good news is that separation anxiety disorder is highly treatable. Typical interventions include Cognitive Behavioral Therapy (CBT), family therapy, pharmacological treatments, or a combination of these treatments. When designing a treatment strategy, clinicians will often consider the client’s temperament, thought patterns, family system, social support, and any acute or chronic life stressors. Developmental stage and parental anxiety/depression might also be assessed for children.
Clients and parents might be asked to keep diaries or logs to assess the antecedents, emotions, thoughts, and behaviors associated with various separation situations occurring throughout the course of the day. The logs can be used to plan treatment strategies, establish a baseline of anxiety (frequency, intensity, the extent it impairs functioning), and to monitor progress.
Therapy
Evidence-based interventions for Separation Anxiety Disorder closely align to the factors presented previously. These interventions include CBT, family therapy/parent training, and pharmacological treatments, or a combination. Given the role that attachment figures (e.g., parents and caregivers) play with separation anxiety disorder, it is essential that they are integrally involved in both treatment planning and implementation.
Cognitive Behavioral Therapy
Cognitive Behavioral Therapy (CBT) is the treatment of choice for separation anxiety disorder. This type of therapy teaches clients to better understand the links between their thoughts, behaviors and actions. They are taught to identify and challenge irrational beliefs, (e.g., “I need to know where my spouse is at all times,” or, “my mother may never come home”). Clients practice generating more realistic thoughts and develop healthier, less anxious thought patterns.
CBT therapists arm clients with relaxation and coping strategies, then systematically challenge them to work through their avoidance behaviors. The challenges are incremental, and every effort is made to ensure client success. For children and teens, rewards are typically used to motivate compliance. Attachment figures are often included in treatment so that they can work on identifying and changing behaviors that might be exacerbating or maintaining the problem.
Parent Training/Family Therapy
These therapies help clients and families to assess their interactions, behaviors, and ways individuals or the entire system might be contributing to and maintaining the client’s separation anxiety. Parent Therapy usually does not involve the child. Instead, parents assess the parent/child interactions, and learn how to help their children emotionally regulate and problem solve. Since anxiety is often inherited, parents are often encouraged to use the same emotion regulation techniques on themselves.9
Attachment figures and separation anxiety disorder individuals often share a dynamic relationship where the behavior of one shapes the behavior of another. Well meaning family members in an attempt to soothe their child or partner, will often help their family member avoid separation instead of helping them to work through it. For example, a spouse chooses to work from home to alleviate his partner’s anxiety. For this reason, it can be helpful to include attachment figures in the therapy.
School Therapy
Having the school team (counselor, nurse, and teacher) as integrated members of the treatment team can be invaluable. It provides the child with a supportive structure and knowledge that when they are anxious, there are people who can help. When school personnel are not in the loop, there is a risk that well meaning teachers, counselors, or nurses will pay too much attention to anxiety symptoms and unknowingly make the problem worse.
Intended Treatment Outcome & Timeline
Reducing anxiety, increasing autonomy, and helping the client achieve a sense of self-efficacy are the goals of separation anxiety disorder therapy. Typically CBT and parent training interventions take 6-12 weeks.
Medication
When symptoms fail to respond to non pharmacological treatments, medication might be added to the regimen. While medication does not cure anxiety disorders, it can alleviate anxiety and allow for more full participation in therapy. Medication for anxiety may be prescribed by psychiatrists, primary care providers, and in some states by specially trained psychologists.
Selective serotonin reuptake inhibitors are considered the first choice drugs in separation anxiety disorder. SSRIs are believed to work by promoting neuroplasticity in the brain. Simply put, higher levels of serotonin promote increased brain flexibility, and may allow more ability for the brain to be modified. This means it can help make therapy more successful.11
If SSRIs do not improve symptoms, then a tricyclic antidepressant might be tried. Tricyclic antidepressants work by preventing the reabsorption of serotonin and norepinephrine, two different neurotransmitters in the brain. If there is too much of either, anxiety symptoms can occur.12
Due to their potential for abuse and dependence, Benzodiazepines (anti-anxiety medications), should be used only when a rapid reduction of symptoms is needed, and only for a few weeks until the SSRI or TCA has become effective. Buspirone should be considered in children who have not responded to other treatments. Further research is needed to confirm efficacy of newer serotonin and norepinephrine reuptake inhibitors (SSNRIs) in the treatment of separation anxiety disorder.3
Getting Help for Separation Anxiety Disorder
When looking for help, it can be hard knowing where to start. Cross referencing local referral lists (general practitioner, pediatrician, school counselor) with a list of providers from your insurance plan is a good start. Employee Assistance Programs (EAPs) can also help by connecting you with local providers, and also can sometimes provide short-term assistance. Your company’s Human Resources Department or the company website can provide their contact information.
Separation Anxiety Disorder Statistics
Children are unable to consistently regulate their emotions and fears about separation until they are approximately 3 or 4 years old. The diagnosis is rarely given before age 5. The average age of childhood separation anxiety disorder is 9, and the lifetime prevalence is 3% to 5% dependent on sex and age. Adolescent onset is rare.
Approximately one third of people who first experience separation anxiety disorder in childhood will carry it into adulthood. In any one year, approximately 4% of children, 1.6% of teens and 0.9 to 1.9% of adults are battling separation anxiety disorder.11,20
Living With Separation Anxiety
Separation Anxiety is highly treatable, however, it’s best to work with a therapist who can guide you through measured steps toward success. However, there are actions you can take to help manage your symptoms, like learning to calm your thoughts and proactively plan for times of separation.
Some strategies that can supplement treatment include:
Calm Down Your Thoughts
Write down or enter into your phone the statements listed below. Read the statements whenever you begin to worry about separating from your attachment figure.
- Separation anxiety disorder is highly treatable
- I am not trapped; I can get better
- Change is always a little uncomfortable
- Just because I feel worried or fearful doesn’t mean something bad is going to happen
- I worry all the time and bad things rarely happen
- Worry doesn’t protect anyone, and only makes me feel miserable
- Most people go out and come home safely
- There have been times in my life that I haven’t been like this, (didn’t worry, didn’t always check on whereabouts), and everything was fine
- This behavior has become a habit, but I can break it
Actively Engage
After reading through the statements above, distract yourself with an engaging activity. If you are at work or school, try refocusing on your work—ask a question in class, engage in conversation with a co-worker or friend.
At other times, or if the above is not engaging enough, take a break—read something, watch a favorite video or TV show, play a video game, or listen to music while coloring or drawing. The key is to lose yourself in an activity, which will help calm you down.
Be Proactive
Plan for separations. Read your statements and know which activities you will engage in while separated. During quiet activities, have another voice playing (music with lyrics you like, audiobook, TV show, guided meditation). This will give you something to refocus on when your worried thoughts push in.
Practice successfully separating. Try short trials and work your way up. Start with 5 minutes and don’t increase separation minutes until you can comfortably separate 3 times at that stage. If 5 minutes causes too much distress, try 2 minutes.
Specific Strategies to Help Your Child With Separation Anxiety Disorder
Anxious children just want to feel safe. Most children with separation anxiety disorder are not motivated to learn how to successfully separate; they are more motivated to achieve the short-term relief of keeping their attachment figure near. If that means shadowing a parent around the house or throwing tantrums unless allowed to sleep near the attachment figure, they are fine with that. The relief that comes from being near the parent or caregiver far outweighs any inconvenience.
Separation Anxiety Disorder is very treatable. It is a disorder, however, that usually needs an integrated approach. Parents, the child, and possibly school personnel all need to do their parts. Cognitions as well as behaviors need to be therapeutically addressed. For those reasons, this disorder is best treated by a licensed therapist.
Some strategies that can help supplement treatment include:
- Keep a log (starting today) of instances of separation difficulties: This will help the therapist guide treatment and will act as a baseline and a measure of progress. Include in the log:
- a short description of the triggering event, (e.g. “was leaving to go to the grocery store without my child”)
- What your child said
- What behaviors your child engaged in (hit me)
- How the incident ended. (cried for 25 minutes and then got distracted by TV)
- Normalize the behavior: Let your child know that many children share the same worried feelings and it’s a very treatable thing.
- Help your child learn relaxation skills: The goal is for your child to be able to use the skill as needed, so you have to practice it often. Deep breathing or a variety of different child-friendly mindfulness exercises could be used.
- Practice separating:
- Set your child up with an activity they love to do.
- Set a timer for the amount of time you are separating and then go.
- Try short trials and work your way up. Start with 3 minutes and don’t increase separation minutes until they can comfortably separate 3 times at that stage. A typical schedule of levels for a child might be 3, 5, 7,10,15, 20, 30 minute intervals
- Reward your child for each level mastered.
- You will probably need to do a few trials per day in order for the new behavior to be established.
