Separation Anxiety Disorder

Normal separation anxiety vs the disorder

Separation anxiety is a normal stage of development. It typically begins around 8 to 10 months, peaks between about 10 and 18 months, and fades by age 3 to 4. Brief distress at drop-off on the first days of school is also common.

Separation anxiety disorder is diagnosed when:

• the fear is excessive for the person's developmental stage
• it lasts at least 4 weeks in children and adolescents, and typically 6 months or more in adults
• it causes significant distress or problems at school, work, home or with friends

Symptoms

The DSM-5-TR lists eight symptoms, and at least three are needed for diagnosis:

1. extreme distress when separating, or expecting to separate, from home or attachment figures
2. persistent worry about losing a loved one or about harm coming to them, such as illness, accidents or death
3. persistent worry that an event will cause separation, such as getting lost or being kidnapped
4. refusing or being reluctant to go out, to school, to work or elsewhere because of fear of separation
5. fear of being alone at home or elsewhere without the attachment figure
6. refusing or being reluctant to sleep away from home or without being near the attachment figure
7. repeated nightmares about separation
8. physical complaints such as headaches, stomachaches, nausea or vomiting when separation happens or is expected

In children

• clinging, crying or tantrums at drop-off
• following a parent from room to room
• school refusal, frequent calls home
• trouble sleeping alone, coming into the parents' bed
• stomachaches and headaches on school mornings

In adults

• constant worry about a partner's or child's safety
• frequent calls or messages to check on them
• avoiding travel, overnight trips or work that involves being apart
• difficulty sleeping when the partner is away
• distress when children leave home

Causes and risk factors

• temperament: shy, cautious or behaviorally inhibited children
• family history of anxiety or depression
• life stress or loss: death of a relative or pet, divorce, moving, a new school, illness
• traumatic events, including disasters or a frightening separation
• parenting patterns that are very protective, which can unintentionally reinforce fear
• other anxiety disorders, such as generalized anxiety disorder and social anxiety disorder

Diagnosis

A pediatrician, psychologist or psychiatrist will talk with the child and parents (or the adult), ask how long symptoms have lasted, what triggers them and how they affect daily life, and may use questionnaires. They check for other anxiety disorders, selective mutism, depression, autism, trauma and medical causes of physical symptoms, and ask about bullying or problems at school.

Treatment

Cognitive behavioral therapy

CBT is the first-line treatment. It helps children and adults:

• understand anxiety and how it affects the body
• recognize and challenge anxious thoughts ("Something bad will happen if I go to school")
• learn calming skills such as slow breathing and relaxation
• face separations gradually, through graded exposure, starting with short, manageable steps

Parent involvement

Parents learn to:

• keep goodbyes brief, warm and consistent
• avoid long reassurance rituals and sneaking away
• praise brave behavior
• reduce accommodations, such as letting a child stay home, gradually
• model calm confidence

Programs such as SPACE (Supportive Parenting for Anxious Childhood Emotions) focus on changing parent responses and are effective even when the child does not attend therapy.

School support

Working with teachers on a plan for a gradual, supported return to school is important when school refusal occurs. A 504 plan can help.

Medicine

For moderate to severe or persistent cases, an SSRI (such as sertraline or fluoxetine) can be added to therapy. Children and teens on SSRIs need monitoring for side effects and mood changes.

Outlook

With treatment, most children improve substantially. Untreated, separation anxiety disorder can lead to ongoing school problems and raise the risk of other anxiety disorders, panic disorder and depression later. Adults also respond well to CBT.

Frequently asked questions

What are the signs of separation anxiety disorder?

Signs include extreme distress when apart from parents or loved ones, constant worry that something bad will happen to them, refusing to go to school or sleep alone, nightmares about separation, and stomachaches or headaches before separations. Symptoms last at least 4 weeks in children.

At what age is separation anxiety normal?

Separation anxiety is a normal part of development from about 8 months to 3 or 4 years, peaking around 10 to 18 months. Brief tears at drop-off when starting school are also normal. Extreme or lasting fear in older children may be a disorder.

Can adults have separation anxiety disorder?

Yes. Adults can have excessive fear of being apart from partners, children or other loved ones, with constant checking, avoidance of travel and difficulty sleeping alone. It sometimes begins in adulthood and responds well to therapy.

How do you treat separation anxiety in children?

Cognitive behavioral therapy with gradual exposure to separations is the main treatment, combined with parent coaching on calm, consistent goodbyes and reducing accommodations. Medicine may be added for severe or persistent cases.