Separation Anxiety Disorder

Separation Anxiety Disorder is generally the earliest anxiety disorder to emerge in childhood (it may be preceded by a specific phobia). Children with separation anxiety disorder live with the fear that a person they care about and rely upon the most- usually a parent- will be taken from them forever, especially if out of their sight. The child with separation anxiety disorder imagines abduction, car accidents, illness or other catastrophic events that will cause this permanent separation. The child tries to avoid temporary separation by clinging, refusing to go out, demonstrating somatic symptoms of distress, or engaging in other behaviors that may keep the other person close. Parents often change their own behavior to spare their child this distress, accommodating and reinforcing the anxiety. 

Symptoms

Separation Anxiety Disorder is characterized by excessive concern regarding separation from home or from attachment figures.  The child with separation anxiety disorder:

  • Worries bad things may happen to parent and/or child
  • Cannot be alone
  • Avoids situations where separation may occur  
  • Has difficulty falling asleep
  • Has physical aches and pains
  • Is often accommodated by adults 
  • Experiences impairment or distress

DSM-5 Criteria

Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following:

  • 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 (e.g., getting lost, being kidnapped, having an 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 (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated.

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

The disturbance causes 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 refusing to leave home because of excessive resistance to change in autism spectrum disorder; 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 generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC

Disorder-specific treatment strategies

Early identification of separation anxiety symptoms allows for parental guidance in reducing accommodations that reinforce separation anxiety symptoms. 

Especially in younger children, therapy strategies must focus on the parents gradually scaling back the behaviors that protect the child from experiencing the separation. 

Separation fears at bedtime may be addressed by reducing the time spent at the bedside at bedtime or moving away from the bedside towards the hall and then toward the kitchen over several nights or giving permission for 2 or 3 verbal callouts (“Are you there, Mom?”) before no longer responding with reassurance.  The child can be rewarded with praise for their bravery with tokens to be redeemed in the morning.

Moderate to severe separation anxiety disorder should be treated with CBT and an SSRI considered.