Separation Anxiety Disorder in Children

When the separation anxiety persists after this time, occurs in older children, adolescents, or adults, or when it causes debilitating anxiety, it may be that the person has SAD.

SAD is a more intense and intrusive condition that can interfere with daily functioning, well-being, academic or work life, or physical health.

Some symptoms of SAD may overlap with those of panic disorder and other anxiety disorders.

SAD is the most common anxiety disorder diagnosed in children, accounting for around 50% of diagnoses (Ehrenreich et al., 2008). Approximately 3-4% of children have SAD (Walker et al., 2009) and up to 6.6% of adults will experience SAD (Silove et al., 2010).

Sometimes a person with SAD as an adult may have had the condition as a child, whilst others may only experience it in adulthood.

Signs of separation anxiety

The symptoms of SAD are usually excessive for the individual’s developmental age. It can cause significant distress in daily functioning and anxiety-related behaviors.

It is important to note that the symptoms of SAD can vary significantly from person to person. It is possible for someone to experience some, but not all, of the symptoms listed in this article.

It is crucial to emphasize that experiencing one or two symptoms alone is not sufficient to self-diagnose themselves. A proper diagnosis can only be made by a qualified mental health professional after a comprehensive evaluation.

Below are some of the cognitive symptoms of SAD:

• Recurrent and excessive distress about anticipating being away from loved ones

• Recurrent and excessive distress about being away from loved ones

• Constant and excessive worry about losing a loved one to an illness or disaster

• Constant worry that something bad will happen, resulting in separation from a loved one

• Not wanting to be home alone without a loved one

• Needing to know where a loved one is at all times

• Feeling anxious about being alone in a room

• Excessive worry about something bad happening to themselves

• Having exaggerated and irrational fears of things like the dark, monsters, or burglars

• Nightmares, specifically about separation

Those with SAD exhibit varying degrees of avoidant behaviors that correlate with the severity of their symptoms. Below are some of the behavioral symptoms of SAD:

• Being clingy

• Extreme and severe crying

• Refusal to do anything that requires separation

• Emotional temper tantrums

• School refusal

• Failure to interact with other children in a healthy way

• Refusing to sleep alone

• Staying close to a parent or loved one, even within the home

• Being shy and socially withdrawn

Older children with SAD may experience school-specific behaviors since school can majorly stress their anxiety. They may feign illnesses or experience headaches when it is time to go to school.

The illness tends to go away once the child is allowed to stay home, but it may reappear before school the next day.

The child may have ‘meltdowns’ or refuse to say goodbye to avoid being separated from the loved one.

Although children with SAD may feign illnesses, they can also experience physical symptoms such as headaches, vomiting, bedwetting, stomach aches, nausea, or problems with sleeping.

Consequences of SAD

Due to SAD, there are many complications that can manifest as a result:

• Poorer school performance

• It can result in other anxiety disorders if left untreated

• Low social performance and high social anxiety

• Difficulty initiating and maintaining friendships

• Family activities are limited by behaviors associated with SAD

• Parents of children with SAD having little to no time for themselves or each other

• Siblings becoming jealous of all the extra attention given to the child with SAD

Consequences for adults with SAD

Adult SAD can be very debilitating. Someone with adult SAD may have problems with their job performance, such as lacking concentration, coming in to work late, or leaving early.

They may find it difficult to maintain employment in general. Adults with SAD may also have difficulties with social and romantic relationships.

They may be seen as too clingy if they constantly want to be with or know where their friends/romantic partners are.

They may also be labeled as annoying and dramatic if they always worry about their friends/romantic partners’ safety or expect something bad to happen.

What can cause separation anxiety disorder?

Several potential causes or risk factors can contribute to the development of separation anxiety disorder.

Environmental factors

SAD may manifest due to environmental factors, especially changes in the environment such as:

• A change in caregiver

• Change in routine

• Following a traumatic event

• Change in parent availability

• Change in family structure, e.g., through divorce or illness

• Moving house

• Starting a new school

• After any life change, even if it’s a positive change

Specifically for adults with SAD, this may develop when dealing with the breakdown of a relationship.

Parents may also develop SAD when their child becomes more independent, no longer relies solely on their parents, or moves away from the family home.

Parenting style

Secure attachment is important for a child’s development. It could be that SAD could be linked to a child’s attachment style to their primary caregiver.

Early experiences of having an insecure attachment style may affect a child’s ability to bond with others and feel safe away from their loved ones.

Likewise, parenting that is overly critical, controlling, or overprotective may interfere with a child’s normal development of autonomy, as well as contribute to anxiety disorders.

It’s been suggested that the effects of parenting styles can be seen in both childhood and after a person enters adulthood (Dabkowska et al., 2011).

Economics

Most children with anxiety disorder usually come from middle-to upper-income families. However, those with SAD tend to come from low-income households (Vine et al., 2012).

This could suggest that the financial stress within a family could be a contributing factor for young children to develop SAD and insecure attachments.

Mental health

SAD may be related to another underlying mental health condition, such as delusions from psychotic disorders or fear of change relating to Autism spectrum disorders.

Individuals with a history of other anxiety disorders or mood disorders, such as generalized anxiety disorder or major depressive disorder, may be at an increased risk of developing separation anxiety disorder.

Temperament

Certain temperaments or personalities of individuals are considered to be more prone to anxiety disorders than others. Specifically, those with timid or shy personalities may be a risk factor for the development of SAD.

Studies have found that low extraversion combined with high neuroticism may play a role in the onset of anxiety disorders (Gershuny & Sher, 1998; Griffith et al., 2010).

Family history

Some research suggests that there may be a genetic component to separation anxiety disorder, meaning that individuals with a family history of anxiety disorders may be more susceptible to developing separation anxiety.

Data suggests that SAD is 20-40% heritable from a biological parent (Fox & Kalin, 2014); therefore, a child may be likely to develop anxiety from their parents.

Diagnosis

A diagnosis of SAD involves determining whether the child is going through a normal stage of development or if the issue is actually a disorder. A doctor may perform medical tests to rule out any physical conditions.

After this, the child’s Paediatrician may refer the parent to a child psychologist or psychiatrist with expertise in anxiety disorders.

To help diagnose SAD, the professional will likely give the child a psychological evaluation, including a structured interview that involves discussing thoughts and feelings.

To diagnose adults, providers primarily rely on self-report methods. Since children cannot reliably be assessed with adult self-reports, parents and professionals must use other methods.

This may involve watching how the parent interacts with the child, which can show whether the parenting style affects how the child deals with anxiety. The parents can also play a role in the assessment by relaying observations they have made of their child.

The Children’s Separation Anxiety Scale (CSAS) lists child-accessible questions such as ‘Do you worry about getting lost?’ and ‘Do you think about going home to be with your mom or dad when you’re at school?’. These child-accessible questions assess whether a child has SAD symptoms.

The DSM-5 defines SAD as a developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidence by at least 3 of the following:

1. Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures.

2. Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death.

3. Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.

4. Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings.

5. Persistent reluctance or refusal to sleep away from home or in other settings.

6. TherapyRepeated nightmares involving the theme of separation.

7. Repeated complaints of physical symptoms (such as headaches, stomach aches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated.

The fear, anxiety, or avoidance must be persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults.

According to the DSM-5, the disturbance should cause clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.

Finally, for a diagnosis of SAD to be made, the symptoms should not be better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in ASD; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in GAD; or concerns about having an illness in illness anxiety disorder.

Treatment Options

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) can help a person identify the thoughts and behaviors that are elevating their SAD symptoms.

With a therapist, the person will learn to challenge their unhelpful thought patterns and adjust these with ones that are adaptive and productive.

Sessions usually last about 12-16 weeks and can teach people with SAD coping techniques for their anxiety, using techniques such as deep breathing and relaxation.

The person with SAD can learn how to face and manage their fears about separation and uncertainty. In addition, parents can get involved in the sessions to learn how to provide emotional support and encourage age-appropriate independence effectively.

Parent-child interaction therapy

Parent-child interaction therapy may also be useful for those with SAD. This therapy usually has three main treatment phases:

• Child-directed interaction – focuses on improving the quality of the parent-child relationship with the aim of strengthening the child’s feelings of safety.

• Bravery-directed interaction – educates the parents about why their child feels anxious. The therapist will develop a bravery ladder that shows situations that cause anxious feelings and establishes rewards for positive reactions.

• Parent-directed interaction – this teaches parents how to communicate clearly with their child so they can help manage unhelpful behaviors from their child.

Contingency management

This type of treatment for SAD is used on children and is based on positive reinforcement. The child and the parent will agree on a set of goals.

When these goals are met, the parent can give the child a reward. This reward can be anything that the child values, such as stickers or extra TV time.

The goal of this treatment operates on the principle that positive behaviors that get rewarded will get repeated.

Exposure therapy

Exposure therapy works on the idea that confronting your fears gives the person a chance to see that their fears are irrational. This usually involves gradually exposing someone to their feared situation, such as being left without a loved one.

This can start small, such as talking about the idea of being left alone, before working up towards being left alone for increasingly longer amounts of time until the person feels comfortable being away from their loved one.

Many times, CBT is often paired with exposure-based treatments, whilst providing people with SAD with ways of coping other than escape and avoidance.

Medication

There are no specific medications for the treatment of SAD. Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) are sometimes used in older children if other forms of treatment are ineffective, but these must be closely monitored for side effects.

Doctors may temporarily prescribe anti-anxiety medications to help a person with their most acute symptoms. However, these are not always long-term solutions to the underlying disorder and some types of anti-anxiety medications can be addictive.

Medications are rarely prescribed as the first line of treatment to children, but for adults, SSRIs may be prescribed on their own but may be more effective as part of combination therapy.

Support groups

Support groups may also be useful for those who have SAD. People who join these groups can gain assistance with learning techniques for reducing SAD symptoms in a group environment.

Administration SA and MHS.  Table 15, dsm-iv to dsm-5 separation anxiety disorder comparison. Updated June 2016.

Dabkowska, M., Araszkiewicz, A., Dabkowska, A., & Wilkosc, M. (2011). Separation anxiety in children and adolescents. In Different views of anxiety disorders. IntechOpen.

Ehrenreich, J. T., Santucci, L. C., & Weiner, C. L. (2008). Separation anxiety disorder in youth: Phenomenology, assessment, and treatment. Psicologia conductual, 16(3), 389.

Fox, A. S., & Kalin, N. H. (2014). A translational neuroscience approach to understanding the development of social anxiety disorder and its pathophysiology. American Journal of Psychiatry, 171(11), 1162-1173.

Gershuny, B. S., & Sher, K. J. (1998). The relation between personality and anxiety: findings from a 3-year prospective study. Journal of abnormal psychology, 107(2), 252.

Griffith, J. W., Zinbarg, R. E., Craske, M. G., Mineka, S., Rose, R. D., Waters, A. M., & Sutton, J. M. (2010). Neuroticism as a common dimension in the internalizing disorders. Psychological medicine, 40(7), 1125-1136.

Silove, D. M., Marnane, C. L., Wagner, R., Manicavasagar, V. L., & Rees, S. (2010). The prevalence and correlates of adult separation anxiety disorder in an anxiety clinic. BMC psychiatry, 10(1), 1-7.

Vine, M., Stoep, A. V., Bell, J., Rhew, I. C., Gudmundsen, G., & McCauley, E. (2012). Associations between household and neighborhood income and anxiety symptoms in young adolescents. Depression and anxiety, 29(9), 824-832.

Walker, L. S., Beck, J., & Anderson, J. (2009). Functional abdominal pain and separation anxiety: helping the child return to school. Pediatric annals, 38(5), 267.